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Indication for Humalog• Humalog ® (100 units/mL) is an insulin analog indicatedto improve glycemic control in adults and children withdiabetes mellitus.Select Safety Information for Humalog• Humalog is contraindicated during episodes ofhypoglycemia and in patients who are hypersensitiveto Humalog or any of its excipients.• Closely monitor blood glucose in all patients treatedwith insulin. Change insulin regimens cautiously.Select Safety Information for Humalog, continued• Hypoglycemia is the most common adverse effect ofHumalog therapy. The risk of hypoglycemia increases withtighter glycemic control. Severe hypoglycemia may be lifethreatening and can cause seizures or death.• Humalog should be given within 15 minutes before orimmediately after a meal.Please see Important Safety Information and Brief Summaryof Prescribing Information on following pages.2 ADVANCE for NPs & PAs

You can’t always be with your patients. But your guidance can be.We understand that it takes more than just medicineto help your patients with type 2 diabetes startingon mealtime insulin therapy. So Lilly Diabetessupports your efforts with an array of insulinproducts, delivery options, and educationalresources to help your patients fit Humalog intotheir lives, even when you can’t be there.Contact your Lilly Diabetes sales representative,call The Lilly Answers Center at 1-800-LillyRx(1-800-545-5979), or visit www.Humalog.com.ADVANCE for NPs & PAs3

Important Safety Information for HumalogContraindications• Humalog ® is contraindicated during episodes of hypoglycemiaand in patients who are hypersensitive to Humalog or any ofits excipients.Warnings and Precautions• Dose Adjustment and Monitoring: Closely monitor bloodglucose in all patients treated with insulin. Change insulinregimens cautiously. Concomitant oral antidiabetictreatment may need to be adjusted.The time course of action for Humalog may vary in differentindividuals or at different times in the same individual and isdependent on many conditions, including delivery site, localblood supply, or local temperature. Patients who change theirlevel of physical activity or meal plan may require insulindose adjustment.• Hypoglycemia: Hypoglycemia is the most common adverseeffect of Humalog. The risk of hypoglycemia increases withtighter glycemic control. Educate patients to recognize andmanage hypoglycemia. Hypoglycemia can happen suddenlyand symptoms may vary for each person and may changeover time. Early warning symptoms of hypoglycemia maybe different or less pronounced under conditions such aslong-standing diabetes, diabetic nerve disease, use ofmedications such as beta-blockers, or intensified diabetescontrol. These situations may result in severe hypoglycemiaand possibly loss of consciousness prior to the patient’sawareness of hypoglycemia. Severe hypoglycemia may belife threatening and can cause seizures or death.Use caution in patients with hypoglycemia unawareness andwho may be predisposed to hypoglycemia. The patient’s abilityto concentrate and react may be impaired as a result ofhypoglycemia. Rapid changes in serum glucose levels mayinduce symptoms similar to hypoglycemia in persons withdiabetes, regardless of the glucose value.Timing of hypoglycemia usually reflects the time-action profileof administered insulins. Other factors such as changes in foodintake, injection site, exercise, and concomitant medicationsmay alter the risk of hypoglycemia.• Allergic Reactions: Severe, life-threatening, generalized allergy,including anaphylaxis, can occur with Humalog.• Hypokalemia: Humalog can cause hypokalemia, which, ifuntreated, may result in respiratory paralysis, ventriculararrhythmia, and death. Use caution in patients who may be atrisk for hypokalemia (eg, patients using potassium-loweringmedications or medications sensitive to serumpotassium concentrations).• Renal or Hepatic Impairment: Frequent glucose monitoringand insulin dose reduction may be required in patients withrenal or hepatic impairment.Important Safety Information for Humalog, continuedWarnings and Precautions, continued• Mixing of Insulins: Humalog for subcutaneous injection shouldnot be mixed with insulins other than NPH insulin. If Humalogis mixed with NPH insulin, Humalog should be drawn into thesyringe first. Injection should occur immediately after mixing.• Subcutaneous Insulin Infusion Pump: Humalog should notbe diluted or mixed when used in an external insulin pump.Change Humalog in the reservoir at least every 7 days. Changethe infusion set and insertion site at least every 3 days.Malfunction of the insulin pump or infusion set or insulindegradation can rapidly lead to hyperglycemia and ketosis.Prompt correction of the cause of hyperglycemia or ketosisis necessary. Interim subcutaneous injections withHumalog may be required. Train patients using an insulinpump to administer insulin by injection and to havealternate insulin therapy available in case of pump failure.• Drug Interactions: Some medications may alter glucosemetabolism, insulin requirements, and the risk forhypoglycemia or hyperglycemia. Signs of hypoglycemiamay be reduced or absent in patients taking anti-adrenergicdrugs. Particularly close monitoring may be required.Adverse Reactions• Adverse reactions associated with Humalog includehypoglycemia, hypokalemia, allergic reactions, injection-sitereactions, lipodystrophy, pruritus, rash, weight gain, andperipheral edema.Use in Specific Populations• Pediatrics: Humalog has not been studied in children withtype 1 diabetes less than 3 years of age or in children withtype 2 diabetes.Dosage and Administration• Humalog should be given within 15 minutes before orimmediately after a meal.Please see Brief Summary of Prescribing Information onadjacent pages.Please see full user manual that accompanies the pen.HI HCP ISI 08JUN2011Humalog ® and Humalog ® KwikPen are registered trademarksof Eli Lilly and Company and are available by prescription only.Humalog Small Steps Support• Tools and resources for your patients and staff• For introducing, initiating, and continuing therapy• May reinforce your instructions• Helps patients fit Humalog into their livesYour patients can enroll at www.Humalog.com/mysmallsteps,you can provide them with a postage-paid enrollmentform, or they can call 1-877-700-STEP (7837).HI76441 0212 PRINTED IN USA ©Lilly USA, LLC 2012. All rights reserved.4 ADVANCE for NPs & PAs

Table 3: Catheter Occlusions and Infusion Site ReactionsHUMALOG(n=38)Regular human insulin(n=39)Catheter occlusions/month 0.09 0.10Infusion site reactions 2.6% (1/38) 2.6% (1/39)In a randomized, 16-week, open-label, parallel design study of children and adolescentswith type 1 diabetes, adverse event reports related to infusion-site reactions were similarfor insulin lispro and insulin aspart (21% of 100 patients versus 17% of 198 patients,respectively). In both groups, the most frequently reported infusion site adverse eventswere infusion site erythema and infusion site reaction.Allergic ReactionsLocal Allergy — As with any insulin therapy, patients taking HUMALOG may experienceredness, swelling, or itching at the site of the injection. These minor reactions usuallyresolve in a few days to a few weeks, but in some occasions, may require discontinuationof HUMALOG. In some instances, these reactions may be related to factors other thaninsulin, such as irritants in a skin cleansing agent or poor injection technique.Systemic Allergy — Severe, life-threatening, generalized allergy, includinganaphylaxis, may occur with any insulin, including HUMALOG. Generalized allergy toinsulin may cause whole body rash (including pruritus), dyspnea, wheezing, hypotension,tachycardia, or diaphoresis.In controlled clinical trials, pruritus (with or without rash) was seen in 17 patientsreceiving regular human insulin (n=2969) and 30 patients receiving HUMALOG (n=2944).Localized reactions and generalized myalgias have been reported with injectedmetacresol, which is an excipient in HUMALOG [see Contraindications].Antibody ProductionIn large clinical trials with patients with type 1 (n=509) and type 2 (n=262) diabetesmellitus, anti-insulin antibody (insulin lispro-specific antibodies, insulin-specificantibodies, cross-reactive antibodies) formation was evaluated in patients receiving bothregular human insulin and HUMALOG (including patients previously treated with humaninsulin and naive patients). As expected, the largest increase in the antibody levelsoccurred in patients new to insulin therapy. The antibody levels peaked by 12 months anddeclined over the remaining years of the study. These antibodies do not appear to causedeterioration in glycemic control or necessitate an increase in insulin dose. There was nostatistically significant relationship between the change in the total daily insulin dose andthe change in percent antibody binding for any of the antibody types.Postmarketing Experience—The following additional adverse reactions have beenidentified during post-approval use of HUMALOG. Because these reactions are reportedvoluntarily from a population of uncertain size, it is not always possible to reliably estimatetheir frequency or establish a causal relationship to drug exposure.Medication errors in which other insulins have been accidentally substituted forHUMALOG have been identified during postapproval use.DRUG INTERACTIONSA number of drugs affect glucose metabolism and may require insulin dose adjustmentand particularly close monitoring.Following are some of the examples:tDrugs That May Increase the Blood-Glucose-Lowering Effect of HUMALOG andSusceptibility to Hypoglycemia: Oral antidiabetic agents, salicylates, sulfonamideantibiotics, monoamine oxidase inhibitors, fluoxetine, pramlintide, disopyramide,fibrates, propoxyphene, pentoxifylline, ACE inhibitors, angiotensin II receptorblocking agents, and somatostatin analogs (e.g., octreotide).tDrugs That May Reduce the Blood-Glucose-Lowering Effect of HUMALOG:corticosteroids, isoniazid, niacin, estrogens, oral contraceptives, phenothiazines,danazol, diuretics, sympathomimetic agents (e.g., epinephrine, albuterol,terbutaline), somatropin, atypical antipsychotics, glucagon, protease inhibitors, andthyroid hormones.tDrugs That May Increase or Reduce the Blood-Glucose-Lowering Effect ofHUMALOG: beta-blockers, clonidine, lithium salts, and alcohol. Pentamidine maycause hypoglycemia, which may sometimes be followed by hyperglycemia.tDrugs That May Reduce the Signs of Hypoglycemia: beta-blockers, clonidine,guanethidine, and reserpine.USE IN SPECIFIC POPULATIONSPregnancy—Pregnancy Category B. All pregnancies have a background risk of birthdefects, loss, or other adverse outcome regardless of drug exposure. This background riskis increased in pregnancies complicated by hyperglycemia and may be decreased withgood metabolic control. It is essential for patients with diabetes or history of gestationaldiabetes to maintain good metabolic control before conception and throughout pregnancy.In patients with diabetes or gestational diabetes insulin requirements may decreaseduring the first trimester, generally increase during the second and third trimesters, andrapidly decline after delivery. Careful monitoring of glucose control is essential in thesepatients. Therefore, female patients should be advised to tell their physicians if they intendto become, or if they become pregnant while taking HUMALOG.Although there are limited clinical studies of the use of HUMALOG in pregnancy,published studies with human insulins suggest that optimizing overall glycemic control,including postprandial control, before conception and during pregnancy improves fetaloutcome.In a combined fertility and embryo-fetal development study, female rats were givensubcutaneous insulin lispro injections of 5 and 20 units/kg/day (0.8 and 3 times the humansubcutaneous dose of 1 unit/kg/day, based on units/body surface area, respectively) from2 weeks prior to cohabitation through Gestation Day 19. There were no adverse effectson female fertility, implantation, or fetal viability and morphology. However, fetal growthretardation was produced at the 20 units/kg/day-dose as indicated by decreased fetalweight and an increased incidence of fetal runts/litter.In an embryo-fetal development study in pregnant rabbits, insulin lispro doses of 0.1,0.25, and 0.75 unit/kg/day (0.03, 0.08, and 0.24 times the human subcutaneous dose of 1unit/kg/day, based on units/body surface area, respectively) were injected subcutaneouslyon Gestation days 7 through 19. There were no adverse effects on fetal viability, weight,and morphology at any dose.Nursing Mothers—It is unknown whether insulin lispro is excreted in human milk.Because many drugs are excreted in human milk, caution should be exercised whenHUMALOG is administered to a nursing woman. Use of HUMALOG is compatible withbreastfeeding, but women with diabetes who are lactating may require adjustments oftheir insulin doses.Pediatric Use—HUMALOG is approved for use in children for subcutaneous dailyinjections and for subcutaneous continuous infusion by external insulin pump. HUMALOGhas not been studied in pediatric patients younger than 3 years of age. HUMALOG has notbeen studied in pediatric patients with type 2 diabetes.As in adults, the dosage of HUMALOG must be individualized in pediatric patientsbased on metabolic needs and results of frequent monitoring of blood glucose.Geriatric Use—Of the total number of subjects (n=2834) in eight clinical studiesof HUMALOG, twelve percent (n=338) were 65 years of age or over. The majority ofthese had type 2 diabetes. HbA1c values and hypoglycemia rates did not differ by age.Pharmacokinetic/pharmacodynamic studies to assess the effect of age on the onset ofHUMALOG action have not been performed.OVERDOSAGEExcess insulin administration may cause hypoglycemia and hypokalemia. Mild episodesof hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage,meal patterns, or exercise may be needed. More severe episodes with coma, seizure,or neurologic impairment may be treated with intramuscular/subcutaneous glucagon orconcentrated intravenous glucose. Sustained carbohydrate intake and observation may benecessary because hypoglycemia may recur after apparent clinical recovery. Hypokalemiamust be corrected appropriately.DOSAGE AND ADMINISTRATIONDosage Considerations—When given subcutaneously, HUMALOG has a more rapidonset of action and a shorter duration of action than regular human insulin.The dosage of HUMALOG must be individualized. Blood glucose monitoring is essentialin all patients receiving insulin therapy.The total daily insulin requirement may vary and is usually between 0.5 to 1 unit/kg/day.Insulin requirements may be altered during stress, major illness, or with changes in exercise,meal patterns, or coadministered drugs.Subcutaneous Administration—HUMALOG should be given within 15 minutes before ameal or immediately after a meal.HUMALOG given by subcutaneous injection should generally be used in regimens withan intermediate- or long-acting insulin.HUMALOG administered by subcutaneous injection should be given in the abdominalwall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region(abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the riskof lipodystrophy [see Adverse Reactions].Continuous Subcutaneous Infusion (Insulin Pump)—HUMALOG may be administeredby continuous subcutaneous infusion by an external insulin pump. Do not use dilutedor mixed insulins in external insulin pumps. Infusion sites should be rotated within thesame region to reduce the risk of lipodystrophy [see Adverse Reactions]. Change theHUMALOG in the reservoir at least every 7 days, change the infusion sets and the infusionset insertion site at least every 3 days.The initial programming of the external insulin infusion pump should be based on thetotal daily insulin dose of the previous regimen. Although there is significant variabilityamong patients, approximately 50% of the total dose is usually given as meal-relatedboluses of HUMALOG and the remainder is given as a basal infusion. HUMALOG isrecommended for use in pump systems suitable for insulin infusion such as MiniMed,Disetronic, and other equivalent pumps.HOW SUPPLIED/STORAGE AND HANDLINGHow SuppliedHUMALOG 100 units per mL (U-100) is available as:10 mL vials NDC 0002-7510-01 (VL-7510)3 mL vials NDC 0002-7510-17 (VL-7533)5 x 3 mL cartridges 1 NDC 0002-7516-59 (VL-7516)5 x 3 mL prefilled pen NDC 0002-8725-59 (HP-8725)5 x 3 mL Humalog KwikPen (prefilled) NDC 0002-8799-59 (HP-8799)StorageDo not use after the expiration date.Unopened HUMALOG should be stored in a refrigerator (36° to 46°F [2° to 8°C]), butnot in the freezer. Do not use HUMALOG if it has been frozen. In-use HUMALOG vials,cartridges, pens, and HUMALOG KwikPen ® should be stored at room temperature,6 ADVANCE for NPs & PAs

elow 86°F (30°C) and must be used within 28 days or be discarded, even if they stillcontain HUMALOG. Protect from direct heat and light. See table below:Not In-Use(Unopened) RoomTemperature (Below86°F [30°C])Not In-Use(Unopened)RefrigeratedIn-Use (Opened)Room Temperature,(Below 86°F [30°C])10 mL vial 28 days Until expiration date 28 days, refrigerated/room temperature.3 mL vial 28 days Until expiration date 28 days, refrigerated/room temperature.3 mL cartridge 28 days Until expiration date 28 days, Do notrefrigerate.3 mL prefilled pen 28 days Until expiration date 28 days, Do notrefrigerate.3 mL HumalogKwikPen (prefilled)28 days Until expiration date 28 days, Do notrefrigerate.Use in an External Insulin Pump — Change the HUMALOG in the reservoir at leastevery 7 days, change the infusion sets and the infusion set insertion site at least every3 days or after exposure to temperatures that exceed 98.6°F (37°C). A HUMALOG 3 mLcartridge used in the D-Tron ® pumps should be discarded after 7 days, even if it stillcontains HUMALOG. However, as with other external insulin pumps, the infusion set shouldbe replaced and a new infusion set insertion site should be selected at least every 3 days.Diluted HUMALOG for Subcutaneous Injection — Diluted HUMALOG may remain inpatient use for 28 days when stored at 41°F (5°C) and for 14 days when stored at 86°F(30°C). Do not dilute HUMALOG contained in a cartridge or HUMALOG used in an externalinsulin pump.Preparation and HandlingDiluted HUMALOG for Subcutaneous Injection — HUMALOG may be diluted with SterileDiluent for HUMALOG for subcutaneous injection. Diluting one part HUMALOG to nine partsdiluent will yield a concentration one-tenth that of HUMALOG (equivalent to U-10). Dilutingone part HUMALOG to one part diluent will yield a concentration one-half that of HUMALOG(equivalent to U-50).PATIENT COUNSELING INFORMATION: See FDA-approved patient labeling and PatientCounseling Information section of the Full Prescribing Information.13 mL cartridge is for use in Eli Lilly and Company's HumaPen ® Memoir and HumaPen ®Luxura HD insulin delivery devices, Owen Mumford, Ltd.’s Autopen ® 3-mL insulindelivery device and Disetronic D-TRON ® and D-TRON ® Plus pumps.Autopen ® is a registered trademark of Owen Mumford, Ltd.Humalog ® , Humalog ® KwikPen, HumaPen ® , HumaPen ® Memoir, HumaPen ®Luxura and HumaPen ® Luxura HD are trademarks of Eli Lilly and Company.Disetronic ® , D-Tron ® , and D-Tronplus ® are registered trademarks of Roche Diagnostics GmbH.MiniMed ® are registered trademarks of MiniMed, Inc.Other product and company names may be the trademarks of their respective owners.Marketed by: Lilly USA, LLC, Indianapolis, IN 46285, USACopyright © 1996, 2011, Eli Lilly and Company. All rights reserved.Additional information can be found at www.humalog.com.HI HCP BS 31AUG2011 PV5533ADVANCE for NPs & PAs7

Here&Now May2012 • Volume 3, Issue 5Don’t miss FREE Mid-Atlantic and Northeastern Regional Online Job Fairs! Register now.Articles20 Insulin TherapyMany clinicians delay the intensification of diabetes management due tolack of sufficient knowledge about insulin agents and how to individualizetherapy. This CME/CE offering presents the essential information in apractical manner, preparing NPs and PAs to initiate insulin in appropriatepatients. (Cover image by Jeffrey Leeser and Doris Mohr)2828 ContraceptionCounseling StrategiesHow can two simple questionsmake a difference in preventingunintended pregnancy? AsSharon Girard, PA-C, explains,asking these questions can openthe door to effective and concisecontraception counseling in allsettings where women are seen.31 Anticoagulants forAtrial FibrillationTwo oral anticoagulants recentlyjoined warfarin as options forpreventing embolic strokeduring atrial fibrillation. JenniferHofmann Ribowsky, MS, RPA-C, and Alison Giordano Ismael,MS, RPA-C, discuss these newmedications and what they meanfor patients.31Columns & DepartmentsFirst & Foremost ..............................12Front & Center ...............................13Career & Workforce ...........................15Role & Growth. ...............................16Calendar ...................................34Ad Index ....................................39Career Opportunities. ..........................44Copyright 2012 by Merion Matters. All rights reserved. Reproduction in any form is forbidden without writtenpermission of publisher. ADVANCE for NPs & PAs (ISSN 1096-6293) is published monthly by MerionPublications, Inc., 2900 Horizon Drive, Box 61556, King of Prussia, PA 19406-0956.ADVANCE for NPs & PAs is the official publication of the Association of FamilyPractice Physician Assistants.ADVANCE is free to certified nurse practitioners and physician assistantsand students with senior status. Our company serves the informational andcareer needs of doctors, nurses and allied healthcare professionals througha wide range of products and services, including magazines, e-newslettersand websites for health information professionals, healthcare executives, hearing healthcare professionals,imaging and radiation oncology professionals, laboratory administrators, long-term caremanagers and professionals, medical laboratory professionals, nurse practitioners and physicianassistants, nurses, occupational therapy practitioners, physical therapy and rehabilitation professionals,respiratory care and sleep medicine professionals, and speech-languagepathologists and audiologists.ADVANCE for NPs & PAs is an official journal of the National Academy ofDermatology Nurse Practitioners.Advance is a member of the National Association for Health Care Recruitment.Periodicals Postage Paid at Norristown, PA and additional mailing offices.Postmaster: send address changes to: ADVANCE for NPs & PAs, CirculationDepartment, Merion Publications, Inc., 2900 Horizon Drive, Box 61556, King ofPrussia, PA 19406-0956.Please Recycle This Magazine®8 ADVANCE for NPs & PAs

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Now atadvanceweb.com/NPPAWhat’s Your Degree Worth?➼ The latest focused report from the 2011 National Salary Survey of NPs& PAs presents information on salary according to academic degree. Whichdegrees lead to the highest pay rates for NPs & PAs? Find out by visiting www.advanceweb.com/NPPAsalaryresults2011.AbdominalAortic Aneurysm➼ Learn about the recognition,management and incidence ofabdominal aortic aneurysmin this exclusive article for ourwebsite. This common conditioncauses 15,000 deaths annually.Smoking and obesity are riskfactors. Find the article byentering “aneurysm” in theSearch Articles box.Are You Up-to-Date?➼ Your work hard to keep pace with numerous changes in clinical care,and we’re pleased to be your partner and resource in this endeavor. AlthoughADVANCE for NPs & PAs is always free to practicing NPs and PAs, postalregulations require us to keep your subscription up-to-date in order for us tocontinue sending the journal. Please take a moment to click the “Subscribe”button at www.advanceweb.com/NPPA to renew your subscriptioninformation. It’s located in the top right corner of the homepage.Everything You Need to Know➼ With summeraround the corner,your patients will beasking for sunscreenrecommendations.The National Academyof Dermatology NursePractitioners sharesdetails in a new articleposted in our Dermatology & Aesthetics specialtyarea. Find it at www.advanceweb.com/NPPAderm.10 ADVANCE for NPs & PAs

Patients with Infertility?Consider natural alternatives beforerecommending IVF or other costlyprocedures.NPPA-1218049Request brochures for your patients orreceive wholesale pricingFairhaven#1 Source for Fertility, Pregnancy & Nursing SupportConceive NaturallyfertliadTrying-To-Conceive ProductsFertility supplements to promote cycle regularityand cervical mucus productionOvulation prediction toolsProducts to support male fertilityPregnancy & Nursing Products4CNatural prenatal supplements with no artificialingredientsPregnancy & NursingBreastfeeding supplements to help improve milkquantity & qualityDoctor- formulated, manufactured in U.S.,GMP- certified facilitiesCall or email today for a wholesale price list or to receive brochures!Phone: 360.543.7888 info@fairhavenhealth.comwww.fairhavenhealth.comAffiliated with:ADVANCE for NPs & PAs11

First&Foremostis published by Merion MattersPublishers of leading healthcare magazines since 1985.Making an ImpactLate this month, several thousand U.S. physician assistantswill be headed north of the border to attend IMPACT 2012, the40 th annual conference of the American Academy of PhysicianAssistants. The venue is the Metro Toronto Convention Centre;see www.aapa.org/impact for more information.This year’s conference features more than 200 CME sessionsranging from evaluating chest pain to providing facialanesthesia to managing chronic kidney disease. Professionaltopics to be covered include PA practice issues in the hospitalsetting, the title change debate and updates to Medicarereimbursement policies.If you are attending the conference, please visit us in the exhibit hall at Booth1021. I’ll be staffing the booth with senior associate editor Jennifer Ford and salesassociate Ashley Hackett. We look forward to meeting you to discuss practice issuesand article ideas.One of the hottest topics of discussion among attendees at the conference may be therecent news about lengthening the PA certification cycle. We reported on this changein our web column about physician assistant issues in April. Find “Physician Assistants,Inside & Out” in the columns area of our website, www.advanceweb.com/NPPA.In this month’s issue, we are proud to present a CME/CE offering that breaksdown insulin therapy into practical steps. As the article explains, many primarycare providers are reluctant to intensify diabetes management because they don’tfeel confident in their knowledge about prescribing an insulin regimen. “The intensificationof therapy for many patients with type 2 diabetes is essential to maintaineuglycemia, and clinicians need to be well prepared to meet the challenges,” writesJane Faith Kapustin, PhD, CRNP, BC-ADM, FAANP, author of the article. “A positiveattitude about the initiation of insulin can help allay patient concerns and fear andhelp overcome many of the other barriers that interfere with timely treatment.”Another article in this issue presents a practical approach to preventing unintendedpregnancy. Sharon Girard, PA-C, explains that the discussion of contraceptionshould not be limited to women's healthcare settings. In all settings where womenare seen, asking two basic questions can go a long way toward reducing unplannedpregnancies.Remember, the clinical and professional information offered by ADVANCE forNPs & PAs is not confined to this print issue. Our website is updated daily with newarticles, columns and blog posts. To receive alerts about updates and highlights,please sign up for our free weekly enewsletter by using the Subscribe tools at the topof our homepage: www.advanceweb.com/NPPA. ■— Michelle Perron PronsatiThe Editor Recommends …➼ Check out our online column, “Physician Assistants, Inside & Out,” for newsand commentary on trends in the PA profession. Find it in the Columns section ofour homepage at www.advanceweb.com/NPPA.PublisherAnn Wiest KielinskiGeneral ManagerW. M. “Woody” KielinskiChief Information OfficerKhader MohammedEditorial StaffEditor: Michelle Perron PronsatiSenior Associate Editor: Jennifer FordEditorial Assistant: Kelly WolfgangWeb Manager: Jennifer MontoneDesignVice President, Director of Creative Services:Susan BasileDesign Director: Walt SaylorArt Director: Doris MohrMultimedia Director: Todd GerberadvertisingDirector of Marketing Services: Christina AllmerArt Director: Chris WoffordEVENTSPublic Relations Director: Maria SeniorJob Fair Manager: Laura SmithEvents Product Manager: Mike ConnorADMINISTRATIONVice President, Director of Human Resources:Jaci NicelyVice President of Business Technology Operations:Joe RomelloInformation & Business Systems Director:Ken NicelyDigital Media Sales Director: Kim NobleCirculation Manager: Maryann KurkowskiBilling Manager: Christine MarvelSubscriber Services Manager: Vikram KhambattaMedia & Marketing OpportunitiesDisplay AdvertisingSales Director: Amy TurnquistManager of Custom Communications and MarketingServices: Shannon Coghlan ReissNational Account Executive: Shannon FergusonSales Associate: Ashley HackettHealthcare Facility AdvertisingSales Director: Kim NobleGroup Manager: Robert MurrayEducation AdvertisingSales Manager: Ed ZetoSenior Account Executive: Brock BamberAccount Executive: Sarah RucinskiCUSTOM PROMOTIONsSales Manager: Mike KerrSenior Account Executives: Noel Lopez,Sue Borjeson-RomanoSales Associates: Bill Egan, Kristen Erskine,Aarika Hoffner, Desirae Slaugh, Gina WillettHow to Contact Us• For a FREE subscription: Call (800) 355-1088 orsign up at www.advanceweb.com/NPPA• To reach the editor:Michelle Perron Pronsati, mpronsati@advanceweb.com or (800) 355-5627, Ext. 1221• To reach the senior associate editor andwebsite editor:Jennifer Ford, jford@advanceweb.com or(800) 355-5627, Ext. 1384• To reach the editorial assistant: Kelly Wolfgang,kwolfgang@advanceweb.com, Ext. 1158• To order article reprints: (800) 355-5627, Ext.1446• To place an advertisement (display, calendar orrecruitment): (800) 355-5627, Ext. 0ADVANCE for NPs & PAsMerion Matters • 2900 Horizon Dr.King of Prussia PA 1940612 ADVANCE for NPs & PAs

Front&CenterBy Kelly WolfgangNews for NPs & PAsChild Obesity a Major Focus at AnnualNAPNAP ConferenceSAN ANTONIO, Texas — Approximately 1,500 pediatricNPs gathered here in late March to focus on the future of childhealth. The 33rd annual conference of the National Associationof Pediatric Nurse Practitioners (NAPNAP) featured abundantlearning and networking activities set against the invitingbackdrop of this river city.A major theme of the conference lineup was the problemof childhood obesity. Keynote speaker Judith S. Palfrey, MD,FAAP, executive director of the First Lady’s Let’s Move! initiative,spoke on the topic and demonstrated her support of physicalactivity by doing jumping jacks on stage. She urged NPs tocontinue action on their commitment to reducing weight andinactivity in children.This commitment was evident in other programming as well.NAPNAP has made childhood obesity a research priority forthe organization, and several speakers presented their findingson this issue (see photo).Sessions on atopic dermatitis and immunization drew capacitycrowds, as did the bustling exhibit hall. At NAPNAP’s businessmeeting, recently hired CEO Sandra Vassos shared her goalsBarbara Synowiecki, MSN, CPNP (left), and Misty Schwartz, PhD, RN,presented their study on parental perception of body mass indexreferrals for overweight school-aged children.of doubling the size of the annual conference, building theNAPNAP brand and strengthening member offerings.At its annual awards breakfast, NAPNAP honored more thantwo dozen NPs and NAPNAP subgroups. Among these wereBarbara Schaffner, PhD, CPNP, who received the GrassrootsAdvocacy Award, and Julie Berndt, who received the LorettaC. Ford Leadership Development Award.NAPNAP will head to Orlando for next year’s conference.The event will be held April 17–20, 2013, at the Hilton Orlandonear Disney World.NCCPA Lengthens the RecertificationCycle for Physician AssistantsThe certification cycle for physician assistants willchange significantly as a result of a recent decision by theNational Commission on Certification of Physician Assistants(NCCPA). The certifying body followed the recommendationof a 2009 task force to extend the cycle by 4 years.Since recertification was mandated in 1981, PAs have beenrequired to retest every 6 years. Beginning in 2014, certified PAswill transition to the 10-year cycle. Those who pass the PhysicianAssistant National Certifying Exam (PANCE) or PhysicianAssistant National Recertifying Exam (PANRE) in 2014 will be thefirst PAs to fall under the new mandate. PAs currently practicingwill move to the 10-year cycle over the following 5 years.The new requirements also include changes to the CME process.PAs will now need to obtain 20 of 50 Category 1 CME creditsthrough self-assessment or performance improvement CME.“I appreciate that NCCPA’s leaders have taken their time withthese discussions and have sought input from AAPA and othersthroughout their consideration of changes to the certificationmaintenance process,” AAPA President Robert Wooten said.For more details on the changes, see our “Physician Assistants,Inside & Out” column at http://nurse-practitioners-and-physician-assistants.advanceweb.com/Columns/Physician-Assistants-Inside-Out/A-Primer-on-the-10-Year-Recertification-Cycle.aspx.AANP Partners WithJoining ForcesAmerican Academy of NursePractitioners (AANP) president PennyKaye Jensen, NP, and First Lady MichelleObama recently recognized nurses' contributionsto the Joining Forces initiative,a veteran-specific care program to offerspecialized programs and activities.With the support of more than 150 stateand national organizations and more than500 universities, Joining Forces aims to meetthe healthcare needs of veterans, activeservice members and their families.AANP will contribute to the effort byreaching out to its members, creating educationprograms and workshops to promotewellness, highlighting veterans’ health duringNP week, bolstering research efforts,and soliciting legislative support.“Nurse practitioners have and continueto play a vital role in addressingthe healthcare needs of veterans andactive service members who suffer frompost-traumatic stress disorder, traumaticbrain injury, depression and other seriouscombat-related issues,” Jensen said.For more information on JoiningForces, head to the Multimedia area ofour website. The American Academy ofPhysician Assistants became involved inthe initiative in 2011.➼ The News Doesn't Stop Here! Find more in the "News & Conferences" area at www.advanceweb.com/NPPA.ADVANCE for NPs & PAs13

Front&CenterGeorgia PAs Prescribe Park FitnessAmy Owen, PA-C, a member of the Georgia Academy of PhysicianAssistants, prescribes a hike for patient Carmen Brown as part of the“Rx for Fitness” program. The program aims to bring fun into healthyliving by “prescribing” hikes, swimming and golfing in the outdoors.Medicaid Access to NPs & PAs in FloridaFlorida Senate Bill (SB) 730 has become law and willprovide Medicaid patients with access to primary care servicesdelivered by NPs and PAs. The bill, which took effect May 12,changes the term “primary care physician” to “primary careprovider.”Susan Lynch, MSN, NP-C, vice chair of public relations forthe Florida Council of Advanced Practice Nurses PoliticalAction Committee (CAP-PAC), believes the legislation willbenefit all Medicaid patients who are currently struggling tofind primary care providers.“There are only 14,000 physician Medicaid providers inFlorida,” Lynch said. “There are an additional 9,000 nursepractitioner Medicaid providers who are a huge part of theprovider network.”California NP Seeks Congressional SeatSusan L. Adams, NP, PhD, is running for Congress inCalifornia’s 2nd district. With 9 years of experience as countydistrict supervisor and 33 years in healthcare, Adams hopes tobring her dedication to community wellnessto Congress.Adams has devoted her work to ensuringall citizens have access to quality and affordablehealthcare through the Marin Healthand Wellness Center, the Emergency MedicalSusan Adams,NP, PHDCorps, which uses volunteer healthcare professionalsto assist in crises, and a therapeuticjustice program that reduces recidivism andpsychiatric emergency visits in local jails.“As someone who has spent a lifetime fighting for healthycommunities and healthy families, I want to use my experienceas a nurse and leader to make access to healthcare a top priorityfor my district,” Adams said. “My perspective as a nurse, aneducator and a locally elected official differentiates me fromthe other candidates. While there are plenty of lawyers andmillionaires in Congress already, there are few nurses withstrong working class values."For more information on Susan Adams and her campaign,visit http://www.susanadamsforcongress.com.NCCPA Foundation Names New PresidentThe National Commission on Certification of PhysicianAssistants (NCCPA) Foundation recently announced the appointmentof Anita Duhl Glicken, MSW, as president.The appointment became effective March 1.At the same time, the NCCPA Foundationannounced that Randy D. Danielsen, PhD,PA-C, will continue as senior vice president.Glicken, a tenured professor at the Universityof Colorado, has served in the medical communityfor more than 30 years. She has writtenmore than 50 published works, served asprinciple investigator on grants totaling morethan $8 million and led several state, nationaland international organizations.Anita DuhlGlicken, MSW,was recentlynamed NCCPAFoundationpresident.“Anita brings with her an impressive track record of launchingexciting initiatives and engaging others in partnership arounda common cause,” said Janet J. Lathrop, MBA, CEO of NCCPAand the NCCPA Foundation. “She also brings rich experiencedesigning, conducting and publishing research for and aboutthe PA profession and healthcare issues.”NP Roundtable Urges Team-Based CareIn an effort to refine the growing practice of teambasedcare, the NP Roundtable recently released a statementon the requirement of individual licensure.The statement proposes the replacement of team-linked care,such as that in Virginia, where NPs practice under physician-ledteams, with team-based care, in which NPs are integrated in ateam of healthcare providers including other disciplines.Commenting on the American Academy of Nurse Practitioners’(AANP) perspective on the issue, Tay Kopanos, DNP, NP, directorof health policy and state government affairs for the organization,said AANP recognizes the value of team-based care andbelieves the requirements and capabilities of NPs should bebased on licensure, determined by the Board of Nursing, notanother team member.“Team-linked licensure does not facilitate improved patientcare,” Kopanos said. “Team-based care is a system approach tocare that integrates multiple providers, often from different disciplines,across settings around the specific needs of the patient.In true team-based care, just as in any team, each team memberis working at the top of his or her education and expertise.”Kopanos said AANP monitors bills and suppors state NPassociations in legislative efforts around the nation, especiallyin the area of patient-centered healthcare homes. For moreinformation, visit http://bit.ly/teambasedcare. ■14 ADVANCE for NPs & PAs

Career&WorkforceTom WhalenWho — or what — isreading your resume?By Renee Dahring, MSN, NPHave you been applying for jobs butgetting no response? You know you area perfect fit for the job, yet it seems yourresume has disappeared into a humanresources black hole? Maybe it has.Read No MoreMany employers have stopped readingresumes. In fact, maybe we should stopusing the term “reading” completely,because only a few select resumes willactually be read or seen by anyone.How can this be true? It’s true becausecomputers don’t read. Meet the “applicanttracking system” or ATS. The ATS is softwaredesigned to automate the process ofsearching for and hiring job candidates.Writing a resume to impress the ATSrequires a different strategy, and the keyto that strategy lies in understanding howthese systems work.A computer reviews a resume much differentlyfrom the way a human does. Forstarters, computers do not read, and they donot think. Computers do something called“parsing.” They scan a document in searchof exact matches to specific key words orpatterns. If your resume contains these keywords, your application will be flagged as amatch. Resumes that do not contain matchinginformation will be ignored.Consider an ExampleLet me give you an example. A clinicseeks an NP or PA for its orthopedicdepartment. The job description statesthat the qualified candidate will haveexperience with “casting, splinting andhospital rounds.” Now let’s say that youare a seasoned orthopedic clinician withexperience in an inpatient setting managingtrauma patients. On your resume,you sum up your experience as “assessingand managing complex fractures andpostsurgical patients.” You are a perfectfit for the job.Not so fast. The computer, via the ATS,skips over your resume because you don’tpossess the correct skills. Why? Becausecomputers don’t read between the lines,draw conclusions or make assumptions.Your resume will go unnoticed becauseyou neglected to state the skills exactlyas they were mentioned in the job ad(casting, splinting and hospital rounds).The employer will not see you as a qualifiedapplicant and you will be left wonderingwhy no one responded to yourapplication.Appearance Doesn’t MatterComputers are unimpressed by howattractive your resume is. When submittinga resume electronically, skip the fancyformatting. An ATS is programmed toparse words and extract information, soit doesn't play very nicely with creativelyformatted documents.When a computer system “handles”your resume, it takes your beautifullyformatted resume and converts it intosomething the computer prefers — whichis actually no format at all. That is to sayit will run all the information togetherinto one big paragraph.This reformatted version is also how itwill be displayed to the eventual humanreader, should it be selected as a match.To you it would look like a mess, butthose of us who review resumes everyRenee Dahring is a family nurse practitioner who practices in correctionalsettings in Minnesota. She has experience as a recruiter and now conductsworkshops on resume writing and interviewing (www.nursepractitionerjobsearch.com). Read more from Dahring in our Career Coach blog at www.advanceweb.com/NPPAblogs.Help the ComputerParse Your Resume◗ Keep the designsimple.◗ Use one font.◗ Left justify thecontents.◗ Don’t use bullets.◗ Give everything start andend dates, even a period ofunemployment.◗ Include your graduation year.day, we have adjusted to this style andwe don’t mind.The worst type for ATS is a resumewith an excessive use of tabs, indents,tables or font changes. This will causethe computer to spit out your resumeas a garbled nightmare. Save the timeand energy it takes to make your resume“pretty.” Craft your resume using onlyone font and no bullet points, and leftjustify all the information.Dates Are EssentialNothing gets past a computer. When youlist previous employers, enter the monthand year you started and ended so thatyou don’t have any gaps in the dates ofyour employment history. Employerscommonly program their computers toeliminate applicants who have been outof work for a period of time.If you have been unemployed, createan entry in your job history (with dates!)for the period you were not working.Briefly state the reason for your absence,i.e., relocation, maternity leave, layoffor whatever. This fix should satisfy thecomputer.Dates are also important when it comesto your education. Ignore any well-meaningadvice you many have received toexclude the date you graduated, in aneffort to avoid age discrimination. Thecomputer doesn’t like when you do that,and just for the record, it never fooled thehuman reviewer, either. ■ADVANCE for NPs & PAs15

Role&GrowthHistory always lendsperspectiveBy James F. Cawley, MPH, PA-CIt’s been nearly a half-century sincethe nurse practitioner and physician assistantroles were established. The creationof these two professions was notablein the evolution of American medicineand nursing, and it marked a significantadvancement in the division of healthcarelabor. Initially, this sociomedicalinnovation was known as the new healthpractitioner movement. 1Only Two EmergedThe new health practitioner movementbegan in the mid 1960s and featured thedevelopment of many educational programsintended to produce new types ofhealthcare professionals. Of the variousprofessionals trained during this time, thetwo professions that became establishedwere the NP and PA professions.A number of factors led to the developmentof the new health practitioner:• demise of the general practitioner• failure of medicine to meet the needsof American citizens• post-World War II populationgrowth• a shortage of primary care providers• a desire for experimentation in medicaleducation• expansion of existing nursing roles.The first nurse practitioner program wasestablished at the University of Coloradoby Henry Silver, a pediatrician, and LorettaFord, a nurse. 2 The first PA program wasstarted at Duke University by Eugene Stead,a physician. The designs of both programsdrew from academic medical education.Of note, other PA programs began almostconcurrently at the University of Coloradoand at the University of Washington. Atthe University of Washington, RichardSmith began the MEDEX program, forwhich previous healthcare experiencewas a key element.Differences NotedThe roots of the PA profession ironicallyincluded the failure of a master of nursingscience program at Duke in the late1950s. It was a venture that Stead hadencouraged. Some argue that this programrepresented a missed opportunityfor nurses to develop an enhanced relationshipwith physicians, a view that haslargely gone unchallenged among nursinghistorians. 3 (To read more about this MSNprogram, enter “Thelma Ingles” in theSearch Articles box at www.advanceweb.com/NPPA.)Clearly, the mutually distrustful positionsof the American Nurses Association(ANA) and the American MedicalAssociation (AMA) during the late 1960scontributed to the lack of understandingand respect between professional nursinggroups and the promoters of PA programs.This morphed into a continuing professionaljealousy, particularly as more nursepractitioner programs arose.Revitalizing CNMsThe new health practitioner movementalso included the revitalization of thenurse midwife.When nursing roles began to expand,the Frontier Nursing Service, establishedin the 1920s, developed the first certificateprogram to prepare family NPs. In 1970,the name of the school was changed toJames F. Cawley is a professor in the Department of Prevention and CommunityHealth in the School of Public Health and Health Services at George WashingtonUniversity in Washington, where he also is the interim chairperson for the department.He is the 2011 recipient of the American Academy of Physician AssistantsEugene A. Stead Jr. Award of Achievement.Contributors to theMovement◗ Decline in generalpractitioners◗ Expanded primarycare shortage◗ Postwar populationboom, leading to more healthcareneedsthe Frontier School of Midwifery andFamily Nursing. 4Dozens more educational programsarose as a result of the new health practitionermovement, and they took on awide variety of configurations and focusareas. The interesting phenomenon wasthe gradual and eventual coalescence ofthis broad range of disparate programsinto the PA and NP professions, now wellestablished in the health system.The turbulent 1960s was a decade ofchange in many areas of U.S. society,and fundamental restructuring of thedivision of medical labor evolved at thistime. The introduction of the PA andthe NP, along with the rebirth of theCNM in North America, representeda major transformation in U.S. medicalpractice. The NP and PA professions werecreated to assume a scope of practicethat includes medical tasks previouslyreserved for physicians, particularly inunderserved and rural areas. NPs andPAs have gained widespread recognitionin nearly all aspects of healthcare deliveryin the United States, and the conceptshave extended globally. ■References1. Sadler AM. Introducing a new professional: thehealth practitioner.In: Lippard VW, Purcell EF, eds. Intermediate-LevelHealth Practitioners. New York, NY: The Josiah Macy,Jr. Foundation; 1973: 1-56.2. Pollitt P, Reesman K. Back to the Beginning.The PA and NP Professions each got a nudge froman MSN program at Duke. ADVANCE for NPs & PAs.2012;2(11):37-39.3. Holt N. Confusion’s Masterpiece: the developmentof the physician assistant profession. Bull HistMed. 1998;72(2):246-278.4. How FNS began. Frontier Nursing Service website.http://www.frontiernursing.org/History/HowFNSbegan.shtm. Accessed March 5, 2012.Tom Whalen16 ADVANCE for NPs & PAs

ProAir ® HFA OFFERS YOURPATIENTS THE BENEFITS OFFLEXIBLE STORAGE &UP TO 24-MONTH EXPIRATIONSome rescue inhalers have strict storage andpriming requirements that may be challengingfor some patients to follow 1ProAir HFA offers your patients flexibilityCan be carried or stored in any position withoutconcerns about dose variability 2,3Does not need to be reprimed if dropped 3 ** Just like all albuterol HFA inhalers, ProAir HFA should always be actuated,primed, and used in an upright position, as well as stored at room temperature(between 59ºF and 77ºF). 3Expirationup to24monthsMay give patientsmore time to useall 200 doses 4To learn more about the many other benefits that ProAir HFA offers, visit ProAirHFA.com/healthcare-professionalsProAir HFA (albuterol sulfate) Inhalation Aerosol is indicated in patients 4 years of age and older for the treatment orprevention of bronchospasm with reversible obstructive airway disease and for the prevention of exercise-inducedbronchospasm.Important Safety Information• Inhaled albuterol sulfate can produce paradoxical bronchospasm that may be life-threatening. It should berecognized that paradoxical bronchospasm, when associated with inhaled formulations, frequently occurswith the first use of a new canister.• Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs in patientswith asthma.• ProAir HFA, as with all sympathomimetic amines, should be used with caution in patients with cardiovasculardisorders (especially coronary insufficiency, cardiac arrhythmias, and hypertension), convulsive disorders,hyperthyroidism, and diabetes.• Potential drug interactions can occur with beta-blockers, diuretics, digoxin, or monoamineoxidase inhibitors, and tricyclic antidepressants.• Do not exceed the recommended dose.• Adverse events, which occurred at an incidence rate of at least 3% with ProAir HFA,include headache, tachycardia, pain, dizziness, pharyngitis, and rhinitis.Please see Brief Summary of full Prescribing Information on the following pages.REFERENCES: 1. Ventolin HFA [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2009. 2. Everard ML,Devadason SG, Summers QA, Le Souëf PN. Factors affecting total and “respirable” dose delivered by a salbutamolmetered dose inhaler. Thorax. 1995;50(7):746-749. 3. ProAir HFA [package insert]. Horsham, PA: Teva Respiratory,LLC; 2010. 4. FDA Letter [January 14, 2008]. Data on file. Teva Respiratory, LLC. 5. Fingertip Formulary ® .Glen Rock, NJ: Fingertip Formulary, LLC; July 2011.Widest andmost preferredformulary coverageamong albuterolinhalers 5ProAir is a registered trademark ofTeva Respiratory, LLC.©2011 Teva Respiratory, LLC112717ADVANCE for NPs & PAs17

BRIEF SUMMARY OF PRESCRIBING INFORMATION FORPROAIR ® HFA (ALBUTEROL SULFATE) INHALATION AEROSOLFor Oral Inhalation OnlySEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION1 INDICATIONS AND USAGE1.1 BronchospasmPROAIR HFA Inhalation Aerosol is indicated for the treatment or preventionof bronchospasm in patients 4 years of age and older with reversibleobstructive airway disease.1.2 Exercise-Induced BronchospasmPROAIR HFA Inhalation Aerosol is indicated for the prevention ofexercise-induced bronchospasm in patients 4 years of age and older.4 CONTRAINDICATIONSPROAIR HFA Inhalation Aerosol is contraindicated in patients with ahistory of hypersensitivity to albuterol and any other PROAIR HFA InhalationAerosol components. Rare cases of hypersensitivity reactions, includingurticaria, angioedema, and rash have been reported after the use of albuterolsulfate [see Warnings and Precautions (5.6)].5 WARNINGS & PRECAUTIONS5.1 Paradoxical BronchospasmPROAIR HFA Inhalation Aerosol can produce paradoxical bronchospasmthat may be life threatening. If paradoxical bronchospasm occurs,PROAIR HFA Inhalation Aerosol should be discontinued immediately andalternative therapy instituted. It should be recognized that paradoxical bronchospasm,when associated with inhaled formulations, frequently occurs withthe first use of a new canister.5.2 Deterioration of AsthmaAsthma may deteriorate acutely over a period of hours or chronicallyover several days or longer. If the patient needs more doses of PROAIR HFAInhalation Aerosol than usual, this may be a marker of destabilization of asthmaand requires re-evaluation of the patient and treatment regimen, givingspecial consideration to the possible need for anti-inflammatory treatment,e.g., corticosteroids.5.3 Use of Anti-inflammatory AgentsThe use of beta-adrenergic-agonist bronchodilators alone may not be adequateto control asthma in many patients. Early consideration should be given toadding anti-inflammatory agents, e.g., corticosteroids, to the therapeutic regimen.5.4 Cardiovascular EffectsPROAIR HFA Inhalation Aerosol, like other beta-adrenergic agonists,can produce clinically significant cardiovascular effects in some patients asmeasured by pulse rate, blood pressure, and/or symptoms. Although such effectsare uncommon after administration of PROAIR HFA Inhalation Aerosolat recommended doses, if they occur, the drug may need to be discontinued.In addition, beta-agonists have been reported to produce ECG changes, suchas flattening of the T wave, prolongation of the QTc interval, and ST segmentdepression. The clinical significance of these findings is unknown. Therefore,PROAIR HFA Inhalation Aerosol, like all sympathomimetic amines, shouldbe used with caution in patients with cardiovascular disorders, especially coronaryinsufficiency, cardiac arrhythmias, and hypertension.5.5 Do Not Exceed Recommended DoseFatalities have been reported in association with excessive use of inhaledsympathomimetic drugs in patients with asthma. The exact cause ofdeath is unknown, but cardiac arrest following an unexpected development ofa severe acute asthmatic crisis and subsequent hypoxia is suspected.5.6 Immediate Hypersensitivity ReactionsImmediate hypersensitivity reactions may occur after administrationof albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema,rash, bronchospasm, anaphylaxis, and oropharyngeal edema. The potential forhypersensitivity must be considered in the clinical evaluation of patients whoexperience immediate hypersensitivity reactions while receiving PROAIRHFA Inhalation Aerosol.5.7 Coexisting ConditionsPROAIR HFA Inhalation Aerosol, like all sympathomimetic amines,should be used with caution in patients with cardiovascular disorders, especiallycoronary insufficiency, cardiac arrhythmias, and hypertension; in patientswith convulsive disorders, hyperthyroidism, or diabetes mellitus; and inpatients who are unusually responsive to sympathomimetic amines. Clinicallysignificant changes in systolic and diastolic blood pressure have been seen inindividual patients and could be expected to occur in some patients after use ofany beta-adrenergic bronchodilator. Large doses of intravenous albuterol havebeen reported to aggravate preexisting diabetes mellitus and ketoacidosis.5.8 HypokalemiaAs with other beta-agonists, PROAIR HFA Inhalation Aerosol may producesignificant hypokalemia in some patients, possibly through intracellularshunting, which has the potential to produce adverse cardiovascular effects.The decrease is usually transient, not requiring supplementation.6 ADVERSE REACTIONSUse of PROAIR HFA may be associated with the following:• Paradoxical bronchospasm [see Warnings and Precautions (5.1)]• Cardiovascular Effects [see Warnings and Precautions (5.4)]• Immediate hypersensitivity reactions [see Warnings and Precautions (5.6)]• Hypokalemia [see Warnings and Precautions (5.8)]6.1 Clinical Trials ExperienceA total of 1090 subjects were treated with PROAIR HFA InhalationAerosol, or with the same formulation of albuterol as in PROAIR HFA InhalationAerosol, during the worldwide clinical development program.Because clinical trials are conducted under widely varying conditions,adverse reaction rates observed in the clinical trials of a drug cannot be directlycompared to rates in the clinical trials of another drug and may notreflect the rates observed in practice.Adult and Adolescents 12 Years of Age and Older: The adverse reactioninformation presented in the table below concerning PROAIR HFA InhalationAerosol is derived from a 6-week, blinded study which compared PROAIR HFAInhalation Aerosol (180 mcg four times daily) with a double-blinded matchedplacebo HFA-Inhalation Aerosol and an evaluator-blinded marketed active comparatorHFA-134a albuterol inhaler in 172 asthmatic patients 12 to 76 yearsof age. The table lists the incidence of all adverse events (whether consideredby the investigator drug related or unrelated to drug) from this study whichoccurred at a rate of 3% or greater in the PROAIR HFA Inhalation Aerosoltreatment group and more frequently in the PROAIR HFA Inhalation Aerosoltreatment group than in the matched placebo group. Overall, the incidence andnature of the adverse events reported for PROAIR HFA Inhalation Aerosol andthe marketed active comparator HFA-134a albuterol inhaler were comparable.Adverse Experience Incidences (% of Patients)in a Six-Week Clinical Trial*Body System/Adverse Event(as Preferred Term)PROAIRHFAInhalationAerosol(N = 58)MarketedactivecomparatorHFA-134aalbuterolinhaler(N = 56)MatchedPlaceboHFA-134aInhalationAerosol(N = 58)Body as a Whole Headache 7 5 2Cardiovascular Tachycardia 3 2 0Musculoskeletal Pain 3 0 0Nervous System Dizziness 3 0 0Respiratory System Pharyngitis 14 79Rhinitis 5 42* This table includes all adverse events (whether considered by the investigatordrug related or unrelated to drug) which occurred at an incidencerate of at least 3.0% in the PROAIR HFA Inhalation Aerosol group andmore frequently in the PROAIR HFA Inhalation Aerosol group than inthe placebo HFA Inhalation Aerosol group.Adverse events reported by less than 3% of the patients receivingPROAIR HFA Inhalation Aerosol but by a greater proportion of PROAIRHFA Inhalation Aerosol patients than the matched placebo patients, whichhave the potential to be related to PROAIR HFA Inhalation Aerosol, includedchest pain, infection, diarrhea, glossitis, accidental injury (nervous system),anxiety, dyspnea, ear disorder, ear pain, and urinary tract infection.In small cumulative dose studies, tremor, nervousness, and headachewere the most frequently occurring adverse events.Pediatric Patients 4 to 11 Years of Age: Adverse events reported in a3-week pediatric clinical trial comparing the same formulation of albuterol asin PROAIR HFA Inhalation Aerosol (180 mcg albuterol four times daily) to amatching placebo HFA inhalation aerosol occurred at a low incidence rate (nogreater than 2% in the active treatment group) and were similar to those seenin adult and adolescent trials.6.2 Postmarketing ExperienceThe following adverse reactions have been identified during postapprovaluse of PROAIR HFA. Because these reactions are reported voluntarilyfrom a population of uncertain size, it is not always possible to reliably estimatetheir frequency or establish a causal relationship to drug exposure. Reportshave included rare cases of aggravated bronchospasm, lack of efficacy,asthma exacerbation (reported fatal in one case), muscle cramps, and variousoropharyngeal side-effects such as throat irritation, altered taste, glossitis,tongue ulceration, and gagging.The following adverse events have been observed in postapproval useof inhaled albuterol: urticaria, angioedema, rash, bronchospasm, hoarseness,oropharyngeal edema, and arrhythmias (including atrial fibrillation,supraventricular tachycardia, extrasystoles). In addition, albuterol, like othersympathomimetic agents, can cause adverse reactions such as: angina, hypertensionor hypotension, palpitations, central nervous system stimulation,insomnia, headache, nervousness, tremor, muscle cramps, drying or irritationof the oropharynx, hypokalemia, hyperglycemia, and metabolic acidosis.7 DRUG INTERACTIONSOther short-acting sympathomimetic aerosol bronchodilators shouldnot be used concomitantly with PROAIR HFA Inhalation Aerosol. If addi-18 ADVANCE for NPs & PAs

tional adrenergic drugs are to be administered by any route, they should beused with caution to avoid deleterious cardiovascular effects.7.1 Beta-BlockersBeta-adrenergic-receptor blocking agents not only block the pulmonaryeffect of beta-agonists, such as PROAIR HFA Inhalation Aerosol, but mayproduce severe bronchospasm in asthmatic patients. Therefore, patients withasthma should not normally be treated with beta-blockers. However, undercertain circumstances, e.g., as prophylaxis after myocardial infarction, theremay be no acceptable alternatives to the use of beta-adrenergic-blockingagents in patients with asthma. In this setting, consider cardioselective betablockers,although they should be administered with caution.7.2 DiureticsThe ECG changes and/or hypokalemia which may result from the administrationof non-potassium sparing diuretics (such as loop or thiazide diuretics)can be acutely worsened by beta-agonists, especially when the recommendeddose of the beta-agonist is exceeded. Although the clinical significance of theseeffects is not known, caution is advised in the coadministration of beta-agonistswith non-potassium sparing diuretics. Consider monitoring potassium levels.7.3 DigoxinMean decreases of 16% and 22% in serum digoxin levels were demonstratedafter single dose intravenous and oral administration of albuterol, respectively,to normal volunteers who had received digoxin for 10 days. The clinicalsignificance of these findings for patients with obstructive airway disease whoare receiving albuterol and digoxin on a chronic basis is unclear. Nevertheless,it would be prudent to carefully evaluate the serum digoxin levels in patientswho are currently receiving digoxin and PROAIR HFA Inhalation Aerosol.7.4 Monoamine Oxidase Inhibitors or Tricyclic AntidepressantsPROAIR HFA Inhalation Aerosol should be administered with extremecaution to patients being treated with monoamine oxidase inhibitorsor tricyclic antidepressants, or within 2 weeks of discontinuation of suchagents, because the action of albuterol on the cardiovascular system may bepotentiated. Consider alternative therapy in patients taking MAO inhibitorsor tricyclic antidepressants.8 USE IN SPECIFIC POPULATIONS8.1 PregnancyTeratogenic Effects: Pregnancy Category C:There are no adequate and well-controlled studies of PROAIR HFA InhalationAerosol or albuterol sulfate in pregnant women. During worldwidemarketing experience, various congenital anomalies, including cleft palateand limb defects, have been reported in the offspring of patients treated withalbuterol. Some of the mothers were taking multiple medications during theirpregnancies. No consistent pattern of defects can be discerned, and a relationshipbetween albuterol use and congenital anomalies has not been established.Animal reproduction studies in mice and rabbits revealed evidence of teratogenicity.PROAIR HFA Inhalation Aerosol should be used during pregnancyonly if the potential benefit justifies the potential risk to the fetus.In a mouse reproduction study, subcutaneously administered albuterolsulfate produced cleft palate formation in 5 of 111 (4.5%) fetuses at an exposureapproximately eight-tenths of the maximum recommended human dose(MRHD) for adults on a mg/m 2 basis and in 10 of 108 (9.3%) fetuses at approximately8 times the MRHD. Similar effects were not observed at approximatelyone-thirteenth of the MRHD. Cleft palate also occurred in 22 of 72 (30.5%) fetusesfrom females treated subcutaneously with isoproterenol (positive control).In a rabbit reproduction study, orally administered albuterol sulfate inducedcranioschisis in 7 of 19 fetuses (37%) at approximately 630 times the MRHD.In a rat reproduction study, an albuterol sulfate/HFA-134a formulationadministered by inhalation did not produce any teratogenic effects at exposuresapproximately 65 times the MRHD [see Nonclinical Toxicology (13.2)].8.2 Labor and DeliveryBecause of the potential for beta-agonist interference with uterine contractility,use of PROAIR HFA Inhalation Aerosol for relief of bronchospasmduring labor should be restricted to those patients in whom the benefits clearlyoutweigh the risk. PROAIR HFA Inhalation Aerosol has not been approvedfor the management of pre-term labor. The benefit:risk ratio when albuterol isadministered for tocolysis has not been established. Serious adverse reactions,including pulmonary edema, have been reported during or following treatmentof premature labor with beta 2-agonists, including albuterol.8.3 Nursing MothersPlasma levels of albuterol sulfate and HFA-134a after inhaled therapeuticdoses are very low in humans, but it is not known whether the componentsof PROAIR HFA Inhalation Aerosol are excreted in human milk.Caution should be exercised when PROAIR HFA Inhalation Aerosol isadministered to a nursing woman. Because of the potential for tumorigenicityshown for albuterol in animal studies and lack of experience with the use ofPROAIR HFA Inhalation Aerosol by nursing mothers, a decision should bemade whether to discontinue nursing or to discontinue the drug, taking intoaccount the importance of the drug to the mother.8.4 Pediatric UseThe safety and effectiveness of PROAIR HFA Inhalation Aerosol forthe treatment or prevention of bronchospasm in children 12 years of age andolder with reversible obstructive airway disease is based on one 6-week clinicaltrial in 116 patients 12 years of age and older with asthma comparingdoses of 180 mcg four times daily with placebo, and one single-dose crossoverstudy comparing doses of 90, 180, and 270 mcg with placebo in 58 patients[see Clinical Studies (14.1)]. The safety and effectiveness of PROAIRHFA Inhalation Aerosol for treatment of exercise-induced bronchospasm inchildren 12 years of age and older is based on one single-dose crossover studyin 24 adults and adolescents with exercise-induced bronchospasm comparingdoses of 180 mcg with placebo [see Clinical Studies (14.2)].The safety of PROAIR HFA Inhalation Aerosol in children 4 to 11 yearsof age is based on one 3-week clinical trial in 50 patients 4 to 11 years of agewith asthma using the same formulation of albuterol as in PROAIR HFA InhalationAerosol comparing doses of 180 mcg four times daily with placebo. Theeffectiveness of PROAIR HFA Inhalation Aerosol in children 4 to 11 years ofage is extrapolated from clinical trials in patients 12 years of age and olderwith asthma and exercise-induced bronchospasm, based on data from a singledosestudy comparing the bronchodilatory effect of PROAIR HFA 90 mcg and180 mcg with placebo in 55 patients with asthma and a 3-week clinical trialusing the same formulation of albuterol as in PROAIR HFA Inhalation Aerosolin 95 asthmatic children 4 to 11 years of age comparing a dose of 180 mcgalbuterol four times daily with placebo [see Clinical Studies (14.1)].The safety and effectiveness of PROAIR HFA Inhalation Aerosol inpediatric patients below the age of 4 years have not been established.8.5 Geriatric UseClinical studies of PROAIR HFA Inhalation Aerosol did not includesufficient numbers of patients aged 65 and over to determine whether theyrespond differently from younger patients. Other reported clinical experiencehas not identified differences in responses between elderly and younger patients.In general, dose selection for an elderly patient should be cautious,usually starting at the low end of the dosing range, reflecting the greater frequencyof decreased hepatic, renal, or cardiac function, and of concomitantdisease or other drug therapy [see Warnings and Precautions (5.4, 5.7)].All beta 2-adrenergic agonists, including albuterol, are known to be substantiallyexcreted by the kidney, and the risk of toxic reactions may be greaterin patients with impaired renal function. Because elderly patients are morelikely to have decreased renal function, care should be taken in dose selection,and it may be useful to monitor renal function.10 OVERDOSAGEThe expected symptoms with overdosage are those of excessive betaadrenergicstimulation and/or occurrence or exaggeration of any of the symptomslisted under ADVERSE REACTIONS, e.g., seizures, angina, hypertensionor hypotension, tachycardia with rates up to 200 beats per minute,arrhythmias, nervousness, headache, tremor, dry mouth, palpitation, nausea,dizziness, fatigue, malaise, and insomnia.Hypokalemia may also occur. As with all sympathomimetic medications,cardiac arrest and even death may be associated with abuse of PROAIRHFA Inhalation Aerosol.Treatment consists of discontinuation of PROAIR HFA InhalationAerosol together with appropriate symptomatic therapy. The judicious use ofa cardioselective beta-receptor blocker may be considered, bearing in mindthat such medication can produce bronchospasm. There is insufficient evidenceto determine if dialysis is beneficial for overdosage of PROAIR HFAInhalation Aerosol.The oral median lethal dose of albuterol sulfate in mice is greater than2,000 mg/kg (approximately 6,800 times the maximum recommended dailyinhalation dose for adults on a mg/m 2 basis and approximately 3,200 times themaximum recommended daily inhalation dose for children on a mg/m 2 basis).In mature rats, the subcutaneous median lethal dose of albuterol sulfate isapproximately 450 mg/kg (approximately 3,000 times the maximum recommendeddaily inhalation dose for adults on a mg/m 2 basis and approximately1,400 times the maximum recommended daily inhalation dose for children ona mg/m 2 basis). In young rats, the subcutaneous median lethal dose is approximately2,000 mg/kg (approximately 14,000 times the maximum recommendeddaily inhalation dose for adults on a mg/m 2 basis and approximately 6,400 timesthe maximum recommended daily inhalation dose for children on a mg/m 2 basis).The inhalation median lethal dose has not been determined in animals.U.S. Patent Nos. 5605674, 5695743, 7105152, 7566445Mktd by: Teva Respiratory, LLCHorsham, PA 19044Mfd by: IVAX Pharmaceuticals IrelandWaterford, IrelandCopyright ©2010, Teva Respiratory, LLCAll rights reserved.PROAIR ® HFA is a registered trademark of Teva Respiratory, LLCManufactured In Ireland Rev. 07/10PA0710PBS-EADVANCE for NPs & PAs19

CME/CE: DiabetesUncomplicatingInsulin TherapyStrategies forinitiation inpatients withtype 2 diabetesBy Jane Faith Kapustin, PhD, CRNP, BC-ADM, FAANPjeffrey leeser/doris mohr20 ADVANCE for NPs & PAs

CME/CE: Diabetes➼ At her initial appointment witha new primary care provider, Ms. Jones, a57-year-old woman diagnosed with type 2diabetes mellitus (T2DM) 7 years earlier,reports that her blood glucose levels havebeen higher than usual for the past severalyears. Today, her hemoglobin A 1c is 8.8%.She reports that her last A 1c — calculateda year ago — was 8.4%. At that visit, herhealthcare provider had encouraged herto lose weight and exercise. The providermade no changes to her oral medicationregimen of metformin 2,000 mg daily,simvastatin 20 mg daily and glipizide10 mg daily. At today’s visit, Ms. Jonesweighs 244 pounds and her body massindex is 33. She apologizes for failing tomanage her diabetes adequately.This is the point at which too manyproviders fail to take further action. Itis tempting to encourage the patient toexercise, lose weight and make better foodchoices. That message is important, butwe should do more to keep the patienton track with glycemic control. In thisscenario, it is important to reinforce toMs. Jones that T2DM is a progressivechronic disease and to explain that it istime to intensify treatment.This scenario is typical of many encountersin primary care today, because T2DMis more prevalent than ever. T2DM is theseventh leading cause of death in this country.1 More than 25.8 million people havebeen diagnosed with this disease, and itsincidence continues to increase. 1 In 2007,U.S. healthcare costs related to diabeteswere estimated at $174 billion annually; atleast half were associated with the treatmentof vascular complications. 2Type 2 diabetes is theseventh leading causeof death in the UnitedStates. More than25.8 million people havebeen diagnosed with thischronic disease.Rationale for Intensifying TreatmentPatients with T2DM have better healthcareoutcomes when euglycemia ismaintained within the parameters recommendedby the American DiabetesAssociation (ADA) and the AmericanAssociation of Clinical Endocrinologists(AACE). The ADA 3 defines glycemiccontrol as maintenance of an A 1c below7%, and the AACE 4 recommends keepingA 1c at or below 6.5%. Data show that manypatients do not meet these goals, puttingthem at risk for developing preventablecomplications. These A 1c goals are difficultto reach using oral agents alonebecause beta cell deterioration and insulinresistance, the core defects associatedwith T2DM, progress over time. 5Intensification of diabetes treatmentis necessary for several reasons. First,cardiovascular disease and microvascularcomplications are in part prevented ordelayed when glycemic levels are optimal.As demonstrated by the Diabetes Controland Complications Trial (DCCT), 6 microvasculardiseases are significantly reducedwhen glycemic goals are maintained.In this large multicenter trial, patientswith type 1 diabetes experienced 54%lower risk for nephropathy, 60% lowerrisk for neuropathy, and 76% lower riskfor retinopathy when A 1c was maintainedat or below 7%. The United KingdomProspective Diabetes Study (UKPDS) 7demonstrated similar results for peoplewith T2DM. In that landmark trial,researchers documented a 21% reductionin diabetes-related deaths and a 37%reduction in microvascular complicationsfor each 1% reduction in A 1c . These seminaltrials reinforced the need for reachingglycemic goals and revolutionized diabetescare in the United States. 6,7T2DM is a progressive disease thatworsens over time, even with appropriatemanagement and careful maintenanceof the treatment regimen. At the time ofdiagnosis, approximately 50% of beta cellfunction may already be lost; declines of3% to 5% occur each subsequent year. 7,8Oral medication is not sufficient tomaintain euglycemia, so eventually mostpatients require insulin. 9-11T2DM is characterized by two maindefects: insulin resistance and beta celldeterioration. As seen with Ms. Jones, betacell function declined over time, leadingto reduced insulin production. She developedsignificant hyperglycemia, signalingthe need to intensify therapy. 5Given the burgeoning numbers ofpeople diagnosed with T2DM and consideringthat most patients are managedin primary care settings, healthcareproviders need to be more comfortablewith initiating insulin. 12 Much evidencesuggests that only half of patients withLearning Objectives1. Discuss evidence-based insulin regimens used with oral agents or as monotherapyto optimize glycemic control.2. Describe how to initiate insulin and calculate initial insulin doses tailored for specific patients.3. Compare and contrast different insulin types in terms of pharmacokinetics, side effects,administration, safety and unique characteristics.4. State the educational goals and best practices for enhancing patient adherence to insulin therapy.Eligibility: This CME/CE article is eligible for 1 AMA PRA Category 1 Credit and 2 CE contact hours. The article is eligible for AMA PRA Category 1 Credit for6 months past the publication date of this issue. It is eligible for CE contact hours for 2 years after the publication date of this issue.ADVANCE for NPs & PAs21

CME/CE: DiabetesT2DM will meet glycemic goals of A 1cbelow 7%. 5,13 Meanwhile, only 26% ofpeople in the United States with diagnoseddiabetes (both types) use insulin. 1That number is quite low consideringthe number of people with T2DM. Theresponsibility for delays in insulin initiationrests with both healthcare providersand patients.Table 1Summary of Glycemic Recommendations forAdults With Diabetes 3Glycemic ValueA 1c < 7%Preprandial glucosePostprandial glucoseRecommended Result70 mg/dL to 130 mg/dL< 180 mg/dLBarriers to Starting InsulinMany clinicians delay the intensificationof diabetes management due to lack ofsufficient knowledge about insulin agentsand how to individualize therapy for eachpatient. 8,14 Many new types of insulin analogsare now available, and choosing thecorrect insulin regimen can be daunting.Another issue is finding sufficient time toinitiate insulin within the context of a primarycare visit. Primary care offices arenot always staffed to provide the patienteducation that is required, and findingappropriate referral services, such as acertified diabetes educator or registereddietitian, can be difficult. 15-17Another common barrier that canresult in clinical inertia is assuming thatthe patient will be resistant or may feeltoo overwhelmed to initiate insulin.Consequently, the discussion about theneed for insulin does not occur and thepatient’s hyperglycemia goes unchecked. 18Too many providers regard insulin as atreatment of last resort. Other providerconcerns include the erroneous beliefthat insulin increases cardiovascularrisks and fears about hypoglycemia andweight gain. 19 Consequently, providersmiss the opportunities to start insulineven when A 1c approaches 9% or riseseven higher. As noted by the UKPDSstudy, earlier initiation of insulin is necessaryto prevent long-term complicationsbecause it inhibits glucotoxicity and mayhelp preserve beta cell mass. 9Some patients are hesitant to start insulin.Fear of needles, weight gain and hypoglycemiaare commonly cited, and manypatients believe that insulin therapy is a signof personal failure or that they are disappointingtheir healthcare providers andfamilies. 8 Some patients may mistakenlyassociate insulin with late development ofcomplications such as dialysis, amputations,or even death. Healthcare providersneed to point out that starting insulinwill help prevent the poor outcomes thatoccur when hyperglycemia is inadequatelymanaged. 18,20When to Start InsulinMost experts agree that therapy shouldbe intensified when one or more oralagents fail to maintain A 1c below 6.5%to 7%. Most oral agents lower A 1c by 1%to 1.5%, so when the level is above 8.5%and the patient is already taking severaloral agents, it is time to consider insulin.Insulin also is a recommended option forthe patient who has not yet started oraltherapy but has an A 1c of 8.5% or greater.Insulin should be started in every patientwhose A 1c is greater than 10%. 12,16,21-23The goal of insulin is to mimic the body’sphysiologic pulsatile release of insulin.Normally, basal insulin is released insmall amounts to suppress catabolism ofmuscle and fat to help regulate hepaticproduction of glucose. Beta cells alsosecrete insulin to manage carbohydrateconsumption and avoid postprandialhyperglycemia. In the presence of food,insulin is normally secreted in two phases.The first is to cover hepatic productionof glucose and the second is to stimulateperipheral glucose uptake. Mostpeople with T2DM lack the first-phaseresponse, so exogenous insulin is neededto simulate this normal physiologicJane Kapustin is an adult nurse practitioner who is board certified in advanced diabetesmanagement. She is the assistant dean for the master’s and DNP programs at the Universityof Maryland School of Nursing in Baltimore and maintains a faculty practice at the Universityof Maryland Medical Center for Diabetes and Endocrinology. She has completed a disclosurestatement and reports no relationships related to this article.basal–bolus secretion. 5,8 Insulin levelsmust be precisely controlled to maintaineuglycemia and prevent hypoglycemia. 9,14The glycemic targets for A 1c , fasting andpostprandial blood glucose levels arelisted in Table 1.The new insulin analogs (rapid and longacting)more closely match the normalphysiologic release of endogenous insulin.Because they provide higher serum levelsof insulin earlier and have a shorter durationof action than older types of insulin,the rapid-acting analogs — lispro, aspartand glulisine — provide more flexibilityfor patients around mealtimes. 5 Additionaladvantages include the ability to reduceunchecked postprandial glucose excursionsand to reduce the risk of severe hypoglycemia.9 See Table 2 for more details.How to Start InsulinThe ideal regimen of insulin is the basal–bolus method because it provides thebest physiologic action and best glycemiccontrol. 4,5,8 But many patients are reluctantto adopt a complicated routine in aninitial attempt, so introducing a simplerroutine may be preferable. Choice ofinsulin and regimen is influenced bymany factors, including the patient’swillingness to inject more than once aday, his or her ability to manage insulininjections (including vision issues), theability to titrate and calculate doses, andcoordination with the patient’s lifestyle. 14Other factors to consider include patientage, work environment, cost and insurancecoverage, cultural influences, andcomorbidities. All of these factors influencethe decision to use basal insulinonce daily, premixed insulin or prandialcoverage added to basal insulin. 12,16,19It is important to note that glycemiccontrol does not need to occur immediately.In fact, it is best to titrate slowly toavoid patient dissatisfaction and danger-22 ADVANCE for NPs & PAs

CME/CE: Diabetesous hypoglycemia. Select a simple routineto get a patient started. Simplicity offersthe patient a chance to gain confidencein the routine before advancing to morecomplex regimens with multiple dailyinjections. 14 One of the easiest ways tostart insulin is to add an evening dose ofbasal insulin to the patient’s oral medications.4 Basal insulin includes NPH (neutralprotamine Hagedorn) and long-acting analogs(insulin glargine and insulin detemir).Advantages of the analog basal insulinsare their 24-hour duration, their oncedailydosing, their association with lesshypoglycemia (especially at night) andtheir predictable effects. Insulin detemir isalso associated with less weight gain than4,14, 24,16NPH or insulin glargine.Another clear advantage to addingbasal insulin is that it is relatively easyto calculate and order. When unsureabout the starting dose, it is safe to start10 units of basal insulin at bedtime asrecommended by the Treat-to-Targetstudy. 12,25,26 For patients with T2DM,the initial dose of basal insulin can beweight-based at 0.15 units/kg/day (0.1to 0.2 units/kg/day is the recommendedrange); however most patients require significantlymore insulin due to high levelsof insulin resistance. 8,11 Basal insulin canbe increased slowly to achieve a fastingglucose level of less than 100 mg/dL. Inthe Treat-to-Target study, average dailydoses required to reach goals were 0.48units/kg/day for insulin glargine and atleast two oral agents. That is equivalentto approximately 44 units of glargine perday for a patient who weighs 200 pounds(200/2.2 = 91 kg; 91 × 0.48 = 44 units).Basal insulin specifically targets fastingblood glucose, so another advantage isthat it is relatively easy for the patient totitrate with minimal assistance. For NPHinsulin, two delivery methods are available:The total dose can be divided in halfand given 12 hours apart, or two-thirdsof the dose can be given in the morningand one-third in the evening (to maximizethe prandial coverage midday). 14Another routine to consider is the use ofbiphased, premixed insulin preparations.This provides basal and postprandialcoverage in one injection. Studies indicatethat this routine can help patientsreach glycemic goals adequately. However,premixed preparations do not allow the“fine tuning” of administration that basal–bolus therapy does. This type of insulin ismore appropriate for patients who desirea simpler routine that requires injectinginsulin only twice a day; it provides basalas well as prandial coverage. 3,4,19 Premixedinsulin can initially be added to the largestmeal of the day, and then a second dosecan be added at breakfast. To calculatethe starting dose of premixed insulin, use0.2 units/kg/day as the basic formula andgive it in two equal divided doses rightbefore a meal. 16 Patients who use premixedinsulin need to be assessed frequently forhypoglycemia; they also should keep afairly consistent routine. 4Choice of insulin routine dependson many factors, including providerpreference and patient issues such asconvenience and willingness to injectonce or multiple times daily. Table 3outlines the primary considerations.Patients can continue their oral medicationsafter adding insulin — with theexception of sulfonylureas, due to the highrisk for hypoglycemia. 27 Continuation ofmetformin assists in improving insulinsensitivity because it reduces gluconeogenesisand the dose of insulin needed.It also assists with weight maintenance.Glucagon-like peptide (GLP-1) analogssuch as exenatide can be continued withmetformin. 12,28Managing and Titrating InsulinSeveral methods for titrating insulin areavailable, and simple adjustment schedulescan be easily implemented by patients.Every 3 days, if the patient’s fasting glucoselevel is above 130 mg/dL, basal insulincan be increased by 2 units. For glucosereadings that are below 70 mg/dL, basalinsulin can be reduced by 10%, or 4 units.Severe reactions warrant a phone call oroffice visit with the prescriber. 14It is important to also consider addingprandial coverage before the basal dosereaches 0.5 units/kg/day. So, in the caseof Ms. Jones, prandial insulin should beadded when her basal dose approaches 45to 55 units daily (244 pounds or 111 kg;110 kg/2 = 55 units of insulin).Prandial coverage can be providedby rapid-acting analog or short-actingregular insulin. As with the analog basalinsulins, the rapid-acting analogs moreclosely mimic physiologic insulin secretion.Their clear advantage over regularinsulin is that they take effect within 10to 15 minutes, peak in 30 to 90 minutesand last for only 3 to 5 hours. Becausethey are absorbed more rapidly thanregular insulin, the analogs can be givenright before a meal and they have a morepredictable duration that will help avoidhypoglycemia. 16Prandial coverage is managed in severalways. 4 The easiest technique is to have theTable 2Insulin Characteristics and Duration of Action 4,8,9Insulin Onset Peak DurationLispro (Humalog) 10–15 min 15–120 min < 5 hrAspart (Novolog) 10–15 min 15–120 min < 5 hrGlulisine (Apidra) 10–15 min 15–120 min 5 hrRegular (R) 30–60 min 2–3 hr 6–8 hrNPH (N) 2–4 hr 6–10 hr 10–16 hrGlargine (Lantus) 2–4 hr No peak 20–24 hrDetemir (Levimir) 1 hr No peak 20–24 hr70%/30%Aspart protamine/aspart50%/50%NPL/lispro75%/25%NPL/lispro30 min 2–12 hr 10–16 hr30 min 3–5 hr 10–16 hr15 min 30–90 min 10–16 hrNPH = neutral protamine Hagedorn; NPL = neutral protamine lisproADVANCE for NPs & PAs23

CME/CE: DiabetesTable 3Insulin Regimens Tailored for Patient Conditions 14–16,21,27,35,37–39Insulin Regimens A 1c Level Glucose Pattern Patient Conditions Treatment Option Monitoring of SMBGBasal onlyA 1c greaterthan 7.5%to 10%High fasting glucoseSome postprandialhyperglycemia (canbe managed withOADs)Reluctant to do MDIStill on oral medsLess aggressivegoals of therapyFears injections1. Insulin glargine ordetemir daily2. NPH at bedtime3. NPH twice dailyFasting glucoseBasal–bolus (MDI)A 1c greaterthan 7.5%Can be matched toany glucose patternfor controlHighly motivatedPoor control on basalonlyNeed for moreaggressive therapyDesires tight controlWilling to test bloodglucose at least 4times dailyUnpredictableschedule1. Basal daily2. Add prandialcoverage beforelargest meal3. Gradually increaseprandial coveragebefore other 2 mealsAllows for flexibleschedule with meals,injectionsMinimum beforeeach meal and atbedtimePremixed insulinwith rapid-actinganalog andintermediate-actingORregular and NPHOnce or twice dailyA 1c greaterthan 7.5%Fasting glucoseelevatedGlucose rises duringdayReluctant to do MDIConsistent dailyroutineOpposed to middayinjectionsFasting and beforesupper if given twicedailyOADs = oral antidiabetic drugs; MDI = multiple daily injections; SMBG = self-monitoring of blood glucosepatient give a fixed amount prior to eachmeal, but that does not allow for adjustmentsbased on current glucose level orthe anticipated carbohydrate ingestion.To get started, the patient can take 5 unitsof rapid-acting insulin (or about 7% of thedaily dose of the basal insulin) before eachmeal. 4 Another technique is to have thepatient calculate the premeal dose basedon the glucose reading right before themeal, following a sliding scale developedfor him or her. And a preferred methodis to give both prandial and correctionalinsulin just before the meal based on theanticipated carbohydrate ingestion. Thisrequires counting carbohydrates correctlyand adjusting the insulin dose.Usually, predetermined insulin-tocarbohydrateratio is used to predict theamount of insulin to be given. A commonratio is 1:10, which means that thepatient will give 1 unit of insulin for each10 grams of carbohydrates in the meal.The ratio can be changed depending onblood glucose readings and amounts ofcarbohydrates eaten at each meal; thepatient may have a different ratio foreach meal. This kind of routine is morecomplex and requires a highly motivatedpatient who can attend diabetes classesor individual sessions with a diabeteseducator or dietitian. 4Adding prandial coverage requires thatpatients monitor blood glucose levels morefrequently. The recommended routine forchecking glucose levels is at least 4 timesa day — before each meal and at bedtime.Patients should bring glucose logs or theirglucose meter to all appointments. Usingthis data, the clinician can make moreaccurate adjustments in insulin dosesto avoid hypoglycemia and prolongedexcursions of hyperglycemia. 3Case 1: Basal–Bolus InsulinConsider the following example of Mr.Smith, a 62-year-old man who was diagnosedwith T2DM 4 years ago. He is currentlytaking insulin glargine 22 units aday and 6 units of prandial coverage threetimes a day, before meals. His glucose levelsfor several days are shown in Table 4.Mr. Smith is experiencing higher fastingreadings each morning and higher levelsafter supper and before bedtime. If he istaking both basal and prandial insulin, theappropriate adjustment is to increase hisbasal insulin by 2 units to target fastingblood glucose levels (increase to 24 unitsdaily) and increase rapid-acting analogbefore supper by 1 to 2 units (increase to7 to 8 units). Mr. Smith should continueto monitor his blood glucose levels andreport them after 1 to 2 weeks for furtheradjustments. All patients should reportepisodes of hypoglycemia for immediatedose reduction, if needed.Giving basal–bolus insulin can bemore challenging, but it provides thebest physiologic match to endogenousinsulin profiles. It is also more flexiblebecause it allows for variable mealtimesand routines. Approximately 50% of thetotal daily dose of insulin should be basalinsulin and the rest should be given as24 ADVANCE for NPs & PAs

CME/CE: Diabeteslong-acting insulin can be injected anytime of the day, the patient should injectat the same time each day. Self-monitoringof blood glucose (SMBG) results shouldbe documented and logs or charts shouldbe brought to each visit; alternatively,the patient can download meter resultsor office personnel can perform this inanticipation of the office appointment.SMBG results are essential for recognizingpatterns in blood glucose readings toensure accurate insulin titration. Patientsneed to engage in SMBG much more frequentlywhen they take insulin, so appropriateadjustments can be made. The ADArecommends that patients check bloodglucose levels at least three times a day ifthey use multiple insulin injections. 3Patients with renal or hepatic dysfunctionare predisposed to hypoglycemiabecause gluconeogenesis and glycogenolysisare affected. The degradation of insulinalso is impaired, making hypoglycemiamore likely. Insulin dose should be loweredto avoid a dangerous response.Patients with pancreatic damage orinjury lose both beta cell and alpha cellfunction. As a result, they lose the protectiveeffects of glucagon and face a muchhigher risk of serious hypoglycemia. 10 Somepatients lose the ability to sense hypoglycemiaand are at high risk for severeconsequences. Events that can lead to lowblood glucose levels, such as inadequatecarbohydrate intake or taking too muchinsulin, should be avoided at all cost. Allhigh-risk patients should wear medicalalert identification. Older adults can be athigh risk for hypoglycemia. The need fortight glycemic control should be evaluatedcarefully, and accepting higher targets forA 1c (8% or less) may be appropriate. 16Seek Full EngagementFor many patients with T2DM, theintensification of therapy is essential tomaintain euglycemia. It is imperativeto individualize the plan of care, andimmersing the patient and his or herloved ones in the plan is helpful. Glucosegoals should be shared with patients tohelp increase the likelihood of treatmentsuccess. Open communication and earlyintroduction to concepts of avoiding diabetescomplications can increase patientacceptance and adherence. 16 Introductionof new delivery devices can help matchthe patient to the regimen more successfully.To help ensure that diabetes-relatedcomplications are prevented, insulin titrationshould continue in order to achieverecommended goals. Insulin therapy doesrequire close monitoring, but treatmentis well tolerated when patients are fullyengaged in SMBG and other aspects oftheir care. Considering the aging of thepopulation and the ever increasing rates ofobesity and T2DM, it is vital for NPs andPAs to be comfortable with the initiationand adjustment of insulin to maintainglycemic goals and avoid or minimizediabetes-related complications. ■References1. 2011 National Diabetes Fact Sheet. U.S.Department of Health and Human Services, Centersfor Disease Control and Prevention. http://www.cdc.gov/diabetes/pubs/factsheet11.htm. Updated 2011.Accessed April 11, 2012.2. Dall TM, et al. The economic burden of diabetes.Health Aff. 2010;29(2):297-303.3. American Diabetes Association. Standards ofMedical Care in Diabetes – 2012. Diabetes Care.2012;35(Supplement 1):S11-S63.4. Rodbard HW, et al. American Association ofClinical Endocrinologists medical guidelines for clinicalpractice for the management of diabetes mellitus.Endocr Pract. 2007;13(Suppl 1):1-68.5. Maharaj S, et al. How to start and optimise insulintherapy: starting insulin therapy in type 2 diabetes canbe challenging. Cont Med Educ. 2010;28(10):458-464.6. Lasker RD. The Diabetes Control andComplications Trial. Implications for Policy andPractice. N Engl J Med. 1993;329(14):1035-1036.7. Tight blood pressure control and risk of macrovascularand microvascular complications in type 2diabetes: UK Prospective Diabetes Study Group 38.BMJ. 1998;317(7160):703-713.8. Tibaldi J. Initiating and intensifying insulin therapyin type 2 diabetes mellitus. Am J Med. 2008;121(6Suppl):S20-S29.9. Hirsch IB, et al. A real-world approach to insulintherapy in primary care practice. Clin Diabetes.2005;23(2):78-86.10. Fowler MJ. Diabetes treatment: Insulin andincretins. Clin Diabetes. 2010;28(4):177-182.11. Hoerger TJ, et al. Is glycemic control improvingin U.S. adults? Diabetes Care. 2008;31(1):81-86.12. Cooppan R. Initiating insulin therapy in patientswith type 2 diabetes: a practical approach. Internet JIntern Med. 2007;6(2). http://www.ispub.com/journal/the-internet-journal-of-internal-medicine/volume-6-number-2/initiating-insulin-therapy-in-patients-withtype-2-diabetes-a-practical-approach.html.AccessedApril 11, 2012.13. Gavin JR, 3rd, et al. A new look at established therapies:Practical tools for optimizing insulin use. DiabetesEduc. 2010;36(Suppl 2):26S-38S; quiz 39S-40S.14. Henske JA, et al. Initiating and titrating insulinin patients with type 2 diabetes. Clin Diabetes.2009;27(2):72-76.15. Karter AJ, et al. Barriers to insulin initiation: thetranslating research into action for diabetes insulinstarts project. Diabetes Care. 2010;33(4):733-735.16. Cobble ME. Initiating and intensifying insulintherapy for type 2 diabetes: Why, when, and how. AmJ Ther. 2009;16(1):56-64.17. Valentine V. Insulin initiation during a 20-minuteoffice visit: Part 2: Making it happen. DiabetesSpectrum. 2010;23(4):260-266.18. Marrero DG. Overcoming patient barriers toinitiating insulin therapy in type 2 diabetes mellitus.Clin Cornerstone. 2007;8(2):33-43.19. Hirsch IB, Vega CP. Optimal initiation of insulinin type 2 diabetes. MedGenMed. 2005;7(4):49.20. Polonsky WH, et al. Are patients with type 2diabetes reluctant to start insulin therapy? An examinationof the scope and underpinnings of psychologicalinsulin resistance in a large, international population.Curr Med Res Opin. 2011;27(6):1169-1174.21. Brunton S. Initiating insulin therapy in type 2diabetes: benefits of insulin analogs and insulin pens.Diabetes Technol Ther. 2008;10(4):247-256.22. Unger J. Insulin initiation and intensification inpatients with T2DM for the primary care physician.Diabetes Metab Syndr Obes. 2011;4:253-261.23. Yeap BB. Type 2 diabetes mellitus -- guidelinesfor initiating insulin therapy. Aust Fam Physician.2007;36(7):549-553.24. Lavernia F. What options are available whenconsidering starting insulin: Premix or basal? DiabetesTechnol Ther. 2011;13(Suppl 1):S85-92.25. Jenkins N, et al. Initiating insulin as part of theTreating to Target in Type 2 Diabetes (4-T) trial: aninterview study of patients’ and health professionals’experiences. Diabetes Care. 2010;33(10):2178-2180.26. Riddle MC, et al. The treat-to-target trial: randomizedaddition of glargine or human NPH insulinto oral therapy of type 2 diabetes patients. DiabetesCare. 2003;26(11):3080-3086.27. Raskin P. Why insulin sensitizers but notsecretagogues should be retained when initiatinginsulin in type 2 diabetes. Diabetes Metab Res Rev.2008;24(1):3-13.28. Hammer H, Klinge A. Patients with type 2 diabetesinadequately controlled on premixed insulin:effect of initiating insulin glargine plus oral antidiabeticagents on glycaemic control in daily practice.Int J Clin Pract. 2007;61(12):2009-2018.29. Bonafede MM, et al. Insulin use and persistence inpatients with type 2 diabetes adding mealtime insulinto a basal regimen: a retrospective database analysis.BMC Endocr Disord. 2011;11:3.30. Rolla AR. Progression of type 2 diabetes and insulininitiation. J Natl Med Assoc. 2011;103(3):241-246.31. Valentine V. Insulin initiation during a 20-minuteoffice visit: Part 1: Setting the scene. Diabetes Spectrum.2010;23(3):188-193.32. Magwire ML. Addressing barriers to insulintherapy: The role of insulin pens. Am J Ther.2010;18(5):392-402.33. Spollett G. Insulin devices: Addressing barriersto insulin therapy with the ideal pen. Diabetes Educ.2008;34(6):957-960, 963, 967.34. Davis SN, et al. Clinical impact of initiatinginsulin glargine with disposable pen versus vial inpatients with type 2 diabetes mellitus in a managedcare setting. Endocr Pract. 2011;17(6):845-852.35. Lee LJ, et al. Predictors of initiating rapid-actinginsulin analog using vial/syringe, prefilled pen, andreusable pen devices in patients with type 2 diabetes.J Diabetes Sci Technol. 2010;4(3):547-557.36. Levy P. Insulin analogs or premixed insulinanalogs in combination with oral agents for treatmentof type 2 diabetes. MedGenMed. 2007;9(2):12.26 ADVANCE for NPs & PAs

CME/CE: DiabetesPharmacology: Insulin Therapy • NPPA21Questions1. Which of the followingstatements is true regarding type 2diabetes mellitus (T2DM)?a. The core defect associated withT2DM is autoimmune beta celldestruction and genetic mutation.b. T2DM is a progressive disorder,requiring the eventual use of insulinin most cases.c. The glucotoxicity associated withT2DM causes little damage to thebeta cells.d. Approximately 75% of betacell destruction has occurred atdiagnosis of T2DM.2. All but which one of the following isa common cause of delay in initiatinginsulin for people with T2DM?a. Clinician inertiab. Fear of weight gain, hypoglycemiaand use of needlesc. Sense of personal failure for thepatientd. Inability of the patient to manipulateinsulin pens and needles3. Which patient represents thebest circumstances for consideringintensive glycemic management?a. Frail 84-year-old man with manycomorbiditiesb. 50-year-old woman who is notaware when she has hypoglycemiac. 28-year-old woman with type1 diabetes for 11 yearsd. 38-year-old man with newlydiagnosed terminal cancer4. Which of the following is arecommended method for initiatinginsulin for a patient?a. Add 0.15 units/kg/day of longactinginsulin once daily.b. Add 5 units of rapid-acting insulinbefore each meal.c. Add 10 units of rapid-acting insulinbefore bedtime.d. Add 20 units of NPH at breakfast.5. What is the primary advantage ofusing biphased insulin?a. It is only given once daily.b. It is easy to titrate with greatprecision.c. It is given twice daily, eliminatingthe need for midday coverage.d. It is given at bedtime and will lastfor up to 24 hours.6. After starting long-acting insulin,it is best to discontinue which one ofthe following medications due to therisk of hypoglycemia?a. Thiazolidinedionesb. Sulfonylureasc. Biguanidesd. Incretin mimetics7. Which one of these is an easyand safe titration algorithm foradjusting basal insulin?a. Increase dose by 2 units everythird day for fasting glucose levels> 130 md/dL.b. Increase dose by 4 units everyother day for fasting glucose levels >110 mg/dL.c. Decrease dose by 15% for fastingglucose levels < 100 mg/dL.d. Decrease dose by 5% for fastingglucose levels < 50 mg/dL.8. When should prandial insulincoverage be started for a patient onlong-acting basal insulin?a. When the basal dose exceeds 0.5units/kg/dayb. When the basal dose exceeds1 unit/kg/dayc. When the basal dose is greaterthan 50 units a dayd. When the basal dose is equal to20 units a day9. What is the primary advantageof rapid-acting analog insulin overregular insulin?a. Analog insulin is less expensive.b. Analog insulin is absorbed lesspredictably than NPH insulin.c. Analog insulin is absorbed moreslowly and lingers for an extended time.d. Analog insulin more closely mimicsphysiologic insulin secretion.10. Which one of the followingshould be emphasized with patientswhen insulin is initiated?a. Severe hypoglycemia is a threatonly with basal insulin coverage.b. All insulin must be refrigerated forthe entire time of use.c. Carry a source of glucose like hardcandy at all times.d. Basal insulin can be given at differingtimes of the day during the week.Evaluation1. The educational objectives wereachieved.a. strongly disagreeb. disagreec. neutrald. agreee. strongly agree2. Based on what you learned inthis article, will you make changesin your practice?a. yesb. noIf yes, please describe the changesyou intend to make: ____________________________________________What barriers to change do youanticipate? _____________________________________________________What strategies or mechanisms willyou apply to overcome these barriers?______________________________________________________________4. The information in the articlewas fair, balanced, free ofcommercial bias and supported byscientific evidence.a. yesb. noIf no, describe the nature of the issue:_______________________________Registration & Answer FormThis activity has been planned and implemented in accordance with the Essential Areasand policies of the Accreditation Council for Continuing Medical Education through thejoint sponsorship of Wayne State University School of Medicine and ADVANCE for NPs& PAs. The Wayne State University School of Medicine is accredited by the ACCME toprovide continuing medical education for physicians.The Wayne State University School of Medicine designates this educational activityfor a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should only claim creditcommensurate with the extent of their participation in the activity.This activity also is approved for 2 CE contact hours. The issuer of CE contact hoursis Merion Publications (a division of Merion Matters), which is approved as a provider ofcontinuing education in nursing by three agencies. For details on CE provider numbers,visit the CE Test Center on our website, www.advanceweb.com/NPPA.Physician Assistant Instructions:To obtain CME credit, send the completed answer form and registrant information toWayne State University School of Medicine, Attn PA, University Health Center 9A, 4201Saint Antoine St., Detroit, MI 48201. Include a check for $10 payable to Wayne StateUniversity. Or fax the completed form and credit card information to (313) 577-7554.Note: Discover and American Express NOT accepted. Test takers who earn a passingscore will receive a CME certificate by mail, or if paying online can receive an onlinetranscript once registered at http://www.med.wayne.edu/cme/calendarTran.html. Forquestions about CME, call Wayne State University at (313) 577-1453. CME form mustbe postmarked or received within 6 months of the last day of the month of this issue.Nurse Practitioner Instructions:To obtain CE contact hours, take this test online at www.advanceweb.com/NPPA andreceive instant test results and a printable CE certificate upon passage. Or fax thecompleted form and credit card information to (610) 278-1426. Or send the completedanswer form and registrant information to Merion Matters CE Program for NPs, 2900Horizon Dr., King of Prussia, PA 19406. Include a check for $10 payable to MerionMatters. This activity is eligible for CE credit for 2 calendar years after publication.Pharmacology: Insulin Therapy may 2012Test NPPA21EvaluationA B C D A B C D A B C D E1.2.3.4.5.6.7.8.9.10.1.2.3.4.Registrant Information (Please print)Subscriber No. (see mailing label) ____ ____ ____ ____ ____ ____ ____ ____ ____Required for Florida NPs: License No. ___________________________________________E-mail Address ______________________________________________________________Name ______________________________________________________________________Address ❏ Work ❏ Home ___________________________________________________City ____________________________________ State ______ Zip Code _______________Phone No. ❏ Work ❏ Home _________________________________________________Payment: $10❏ For PAs: Check Payable to Wayne State University❏ For NPs: Check Payable to Merion Matters❏ For PAs or NPs: Credit Card No. ________________________ Exp. Date___________Cardholder Name ________________________________________________________Signature _______________________________________________________________❏ American Express (NPs only) ❏ Visa ❏ MasterCard ❏ Discover (NPs only)Statement of CompletionI attest to having completed the CME/CE activity.Signature _____________________________________________ Date _________________Profession ❏ Nurse Practitioner ❏ Physician AssistantADVANCE for NPs & PAs27

Women’s Healthwilling. With an open discussion of birthcontrol, clinicians can positively addressmethod side effects and help dispel mythsand untruths. 10The Teachable MomentWomen present to primary providersfor a variety of reasons, and they sometimesinclude family planning. In a busypractice, a patient’s specific problem isaddressed. But without additional attentionto family planning questions, manyof these women may not seek any othercontraception services due to constraintson time, money or inclination. A teachablemoment is then missed. After reviewing aprimary care patient’s medication historyand not seeing a hormonal method listed,it is fair to ask one simple question: Whatdo you do to avoid pregnancy?Some women simply forget or may notrecognize that the pill, patch, ring or contraceptiveimplant is a medication. A busyprovider can easily make a difference inthese women’s lives by seeking to addressthis issue. With one simple leading questionafter reviewing the medical historyand medication list, a provider can assesa woman’s need for further counseling.A woman will either state her method orsay she wants a pregnancy. If a pregnancyis planned, the provider can stop there(unless health issues need exploration).If a woman answers that she is not usinga specific method or seems interestedin exploring this area further, the nextquestion is: How important is it for youto not be pregnant?Women of all ages may rely on the withdrawalmethod and not initially admit toit. Research shows that adolescent use ofwithdrawal is significant. 11 And in a studyof urban adults, 12 withdrawal was popularbut rarely discussed with healthcare providers.Be proactive in asking questionsabout use of this method.Some women may be ambivalent aboutpregnancy, but many will be certain. Ineither situation, simply letting the patientknow you are open to this discussionTable 1Contraceptive Methods and Effectiveness 14Methodis important and may ultimately leadto a dialogue — at that visit or in thefuture. If preventing pregnancy is of anyimportance, the following two-questioncounseling method may be employed.Two Key Questions1. When do you think you would like tobecome pregnant? Planning to becomepregnant within a year means the womanhas a need for fertility to resume quickly.Therefore, easily reversible methodswould be preferred (Table 2).2. Is a normal regular period necessaryand/or important to you? In many cultures,regular monthly bleeding is viewedas a sign of health. Even after education,many women continue to prefer havinga monthly flow. Menstruation signals anonpregnant state and can be reassuring.This does not mean you cannot provide aWomen who experienceunintended pregnancywithin first year of useTypical UsePerfect UseWithdrawal 27% 4%Condom 15% 2%Combined or progestin pill 8% 0.3%Evra Patch 8% 0.3%NuvaRing 8% 0.3%Depo-Provera 3% 0.3%ParaGard IUC 0.8% 0.6%Mirena IUS 0.2% 0.2%Implanon 0.05% 0.05%Sterilization (women) 0.5% 0.5%Table 2Preferred Methods for Short-Term Birth ControlOral Contraceptives, Patch, Vaginal RingThese methods are easily reversible and return to fertility is immediate after last menses.CondomsEasily reversible, available without a prescription, no side effects.simple explanation such as, “Continuouscontraception with irregular or absentperiods is healthy and safe.”A hesitation or refusal by the patientmay signal that a woman may be moreresistant to a method that eliminatesor changes the monthly pattern of herflow. She may then be less adherent orunhappy with that chosen method. Later,if a woman expresses dissatisfaction withher choice, another discussion may beginto alleviate concerns and bring her closerto accepting a method she had previouslydisregarded (Table 3).With these two simple questions, youcan easily narrow preferable choices forthe patient. When a woman presents forcontraception, she may not know whatmethod she prefers. Or, she may ask abouta method that is used by friends or family,due to lack of knowledge about otherCultural Issues & Contraception➼ What's the importance of cultural competence when providing contraception counseling? Read our onlinearticle to find out. Search for the author, "Cristi Coursen," at www.advanceweb.com/NPPA.ADVANCE for NPs & PAs29

Women’s HealthFREEOnlineOpen HouseOTC MULTIPURPOSEMOISTURE BARRIERTEMPORARILY RELIEVESDISCOMFORT & ITCHINGProtects and Helps HealSkin Irritations from:• Incontinence of Urine orFeces• Diaper Rash• Wound Drainage• Minor Burns, ScrapesCALL1-800-800-3405For moreinformationand free sampleswww.calmoseptineointment.comLourdes Health SystemTuesday, May 15 • 9am-12pm ETNow Hiring RNs,NPs and PAs inNew JerseyREGISTER RIGHTAWAY FOR THISFREE ONLINEOPEN HOUSE!Lourdes Health System has job openings!Sign up to see all of the great career opportunitiesLourdes Health System has to offer in New Jersey.You can attend from anywhere you can get online!This event is perfect for anyone who lives in NewJersey or is looking to relocate to the area.■ Check out their facilities and benefits throughmultimedia features■ Chat live with recruiters looking tofill positions immediately■ Submit your resume■ Review downloadable resources■ And much more!Visit www.advanceweb.com/events or call 800-546-4987.Table 3For Women Who DesireRegular MensesPreferredOral Contraceptives, Ring, PatchThese contain estrogen, which regulates menses.ParaGard Intrauterine DeviceProduces no change in a woman’s normal cycle, except possibleincreased flow or cramping.CondomsThis is not a hormonal method.ESSURE or Tubal LigationThis method does not change menstruation and is permanent.Not PreferredMirena Intrauterine SystemThe progesterone component deregulates monthly flow.Implanon ImplantThis method produces irregular bleeding or spotting.DMPA (Depo-Provera)Amenorrhea or irregular bleeding is common and expected.Progesterone-Only Pill (POP)This method produces irregular bleeding.methods. The leading method among U.S. women ages 15 to44 is the birth control pill. 13 The second leading method issterilization. Unfortunately, many women think condoms andpills are their only reliable choices. A primary care providercan be an invaluable source of information — and is morereliable than the Internet or friends.Safety and Side EffectsA discussion of method choice may lead to questions aboutside effects and safety. Myths about birth control abound, andit is important to provide a clear factual picture. The pill isblamed for weight gain, libido changes and multiple other sideeffects. Depo-Provera is blamed for weight gain. Intrauterinecontraception (IUC) is blamed for infertility, infection anddisease. Most of these claims are untrue and stem from early,inaccurate studies using older devices and doses. The Internetis filled with inaccuracies and innuendo, yet women commonlyturn to it as a source of medical information. A provider cancorrect these falsehoods.Uh-Ohs and Sure ThingsFor years IUC use was discouraged in adolescents, womenwho had never been pregnant, who had a history of pelvicinflammatory disease (PID) or who were at risk for sexuallytransmitted infections (STIs). Newer data dispute theselimitations. Statistics and recent research show that IUCsare used successfully and safely by adolescents, patientswith previous STIs or PID, and women who have never beenpregnant. Because a provider has important influence on aContinued on page 3830 ADVANCE for NPs & PAs

PharmacologyTom whalenOral AnticoagulantsFor Atrial FibrillationWhich one to choose?By Jennifer Hofmann Ribowsky, MS, RPA-C, and Alison Giordano Ismael, MS, RPA-C➼ Two oral anticoagulants,dabigatran and rivaroxaban, recentlyjoined warfarin as options for preventingembolic stroke during atrial fibrillation.Warfarin is the gold standard treatmentfor this indication, but it has significantlimitations. Drug and food interactionsare common with warfarin and can eitherincrease or decrease its antithromboticeffects. Warfarin requires frequent internationalnormalized ratio (INR) monitoringand despite close clinical attention,40% of patients do not achieve INRswithin the recommended range (target2.5, range 2.0 to 3.0). 1Dabigatran EtexilateDabigatran etexilate (Pradaxa) was thefirst oral anticoagulant approved inmore than 50 years. It is a prodrug ofJennifer Hofmann Ribowsky is an assistant professor and the academic coordinatorfor the physician assistant program at Pace University–Lenox Hill Hospital in New York, N.Y.She has a master’s degree in clinical pharmacology. Alison Giordano Ismael is anassistant professor and the clinical coordinator for the physician assistant program at PaceUniversity–Lenox Hill Hospital. The authors have completed disclosure statements and reportno relationships related to this article.dabigatran, which is a direct thrombininhibitor. 2 Pradaxa has an FDA-approvedindication for the reduction of embolicstroke during atrial fibrillation. Dosingin patients with normal renal function is150 mg (capsule) twice daily. In patientswith creatinine clearance (CrCl) of 15 mL/min to 30 mL/min, dosage is adjusted to75 mg twice daily. 2When converting a patient from warfarinto Pradaxa, discontinue warfarinand start Pradaxa when INR is less than2. Converting a patient from Pradaxa towarfarin depends on the patient’s creatinineclearance. Pradaxa does not requirelaboratory monitoring or frequent dosageadjustments, and it has fewer drug interactionsand no known food interactions. Itis short acting with a half-life of 12 to 17hours, and its anticoagulant effects wearoff in approximately 2 days.Warfarin can be reversed with oralor parenteral vitamin K; there is no specificantidote for Pradaxa. Pradaxa costsapproximately $260 per month whilewarfarin costs about $80 per month,including INR monitoring. 2Efficacy: Pradaxa’s approval in theUnited States was based on results fromthe Randomized Evaluation of Long-termAnticoagulation Therapy (RE-LY) noninferioritystudy (n = 18,113). 3,4 Patientswith atrial fibrillation and stroke riskwere randomized to receive Pradaxa 110mg or 150 mg twice daily or an adjusteddose of warfarin. 4 The primary outcomewas stroke or systemic embolism, with asafety outcome of major hemorrhage. Theefficacy of Pradaxa 150 mg twice dailyfor preventing stroke or systemic embolismwas superior to warfarin (relativerisk, 0.66; 95% confidence interval [CI],0.53 to 0.82; P < 0.001). 4 In the warfaringroup, INR values were in the therapeuticrange — a mean of 64% of the time inthis trial. 4Safety and tolerability: Pradaxa is associatedwith an increased risk for gastrointestinal(GI) adverse effects comparedto warfarin (35% vs. 24%). 3,4 Dyspepsiaand gastritis-like symptoms are themost commonly reported GI effects.The primary safety outcome from theRE-LY trial was major hemorrhage, whichADVANCE for NPs & PAs31

Pharmacologyoccurred at similar rates in the group thatreceived 150 mg Pradaxa (3.1%/year) andthe group that received warfarin (3.3%/year). Pradaxa was associated with asignificantly increased risk for GI bleedscompared to warfarin and a lower riskof intracranial hemorrhage comparedto warfarin.RivaroxabanRivaroxaban (Xarelto) was initiallyapproved for the prevention of deep veinthrombosis and pulmonary embolismafter elective total hip or knee replacementsurgery. Recently, it was approvedfor anticoagulation treatment of nonvalvularatrial fibrillation. 5 Xarelto is adirect factor Xa inhibitor, and Pradaxais a direct thrombin inhibitor. 2The recommended dose for Xareltois 20 mg taken orally once daily at nightwith food. If CrCl is 15 mL/min to 50mL/min, the dose is 15 mg with the eveningmeal. Avoid prescribing Xareltofor patients with CrCl < 15 mL/min. Itis contraindicated in patients with liverdisease and bleeding risk. 5 The meanhalf-life for Xarelto is 5 to 9 hours inotherwise healthy patients ages 20 to45 and 11 to 13 hours in patients olderthan 65.When converting a patient from warfarinto Xarelto, stop warfarin, then startrivaroxaban when INR < 3. Avoid usewith drugs that are both p-glycoproteinand strong CYP3A4 inhibitors (e.g., ketoconazole,itraconazole, voriconazole,posiconazole, ritonavir, clarithromycin,conivaptan). Strong CYP3A4 inducers(e.g., rifampin, carbamazepine, phenytoin,St. John’s wort) may decrease theefficacy of Xarelto.Efficacy: Xarelto’s approval in theUnited States was based on results fromthe Rivaroxaban Once Daily Oral DirectFactor Xa Inhibition Compared WithVitamin K Antagonism for Preventionof Stroke and Embolism Trial in AtrialFibrillation (ROCKET-AF) study (n =14,264). The study found Xarelto to benoninferior to warfarin for the preventionof stroke or systemic embolism. 6Patients with nonvalvular atrial fibrillationand with moderate to high riskfor stroke were randomized to receiveeither Xarelto 20 mg daily (15 mg dailyfor patients with CrCl of 30 mL/min to49 mL/min) or warfarin adjusted dose.The primary outcome of the study wasstroke (ischemic or hemorrhagic) andsystemic embolism.Pradaxa and Xarelto are reasonable (but expensive)alternative choices for patients on warfarin in whomtherapeutic INR levels are difficult to consistentlymaintain.The efficacy of Xarelto 20 mg daily forpreventing stroke and systemic embolismwas superior to warfarin. Patients in theXarelto group had a lower rate of strokeand systemic embolism, 1.7% per year,than those in the warfarin group, 2.2%per year (hazard ratio, 0.79; 95% confidenceinterval, 0.66 to 0.96; P < 0.001).In the warfarin group, INR values werein the therapeutic range a mean of 55%of the time. 6Safety and tolerability: Xarelto hadrates of major bleeding comparable tothat of warfarin (14.5% vs. 14.9% per year,respectively). In fact, the risk of intracranialbleeding is lower with Xarelto thanwith warfarin (0.5% vs. 0.7% per year,respectively), but the risk of GI bleedingincreases, 3.2% for Xarelto compared to2.2% for warfarin. 6Expensive AlternativesPradaxa and Xarelto are expensive alternativesto warfarin, which is the standardmedication for preventing stroke or systemicembolism during atrial fibrillation.Get More Prescribing InfoRandomized trials documented comparableefficacy and safety to warfarin. 4,6 Oneadvantage of both Pradaxa and Xarelto isthat they do not require any laboratorymonitoring for dose adjustment, whichsaves both time and money.Although the overall bleeding risk isabout the same for Pradaxa, Xarelto andwarfarin, caution should be used. If bleedingdoes occur, either spontaneously orfrom trauma, no drug reversal for Pradaxaand Xarelto exists. 2Reversal of Pradaxa and Xarelto involvesstopping the drug and waiting until drugwashout occurs, which can take as longas 13 or more hours.Warfarin is easily reversible with vitaminK or fresh frozen plasma. AlthoughPradaxa is dialyzable, Xarelto cannot bedialyzed. 2Pradaxa and Xarelto are reasonablealternative choices for patients on warfarinin whom therapeutic INR levelsare difficult to consistently maintain.They also are reasonable alternatives forpatients for whom access to monitoringlaboratories is difficult.Warfarin continues to be a reasonablechoice for patients who are concernedabout medication cost, for patients whoare comfortable with the necessary INRmonitoring, for patients whose INR levelis consistently therapeutic, for patientswho are not likely to adhere to the twicedailydosing of Pradaxa, and for patientswho do not have access to once-a-dayXarelto. ■References1. del Zoppo GJ, et al. New options in anticoagulationfor atrial fibrillation. N Engl J Med. 2011;365(10):952-953.2. New drug: Pradaxa (dabigatran). Pharmacist’sLetter/Prescriber’s Letter. 2010;26(11):261101.3. Product information for Pradaxa. BoehringerIngelheim Pharmaceuticals, Inc. Ridgefield, CT.November 2011.4. Connolly SJ, et al. Dabigatran versus warfarinin patients with atrial fibrillation. N Engl J Med.2009;361(12):1139-1151.5. Product information for Xarelto. JanssenPharmaceuticals, Inc. Titusville, NJ. November 2011.6. Patel MR, et al. Rivaroxaban versus warfarinin nonvalvular atrial fibrillation. N Engl J Med.2011;365(10):883-891.➼ Jennifer Hofmann Ribowsky writes a new pharmacologycolumn for our website. Look for "Pharmacology Today" in theColumns area at www.advanceweb.com/NPPA.32 ADVANCE for NPs & PAs

FREE HEALTHCAREJOB FAIRS & SESSIONSTake the Next Step toa Brighter FutureONLINESign up to attend a FREE online job fair rightat home! Chat with recruiters, gather infoand instantly submit your resume.June 6Mid-Atlantic & Lower Great Lakes Regionalwww.advanceweb.com/eventsFREE SESSIONS• Genetics• Helping Consumers Navigate HealthcareEXHIBITORSFavorite Healthcare StaffingJune 20Northeastern Regionalwww.advanceweb.com/eventsFREE SESSIONS• Genetics• Helping Consumers Navigate HealthcareEXHIBITORSFavorite Healthcare StaffingSt. Mary’s Healthcare System for ChildrenLIVE ONLINE EVENTS RUN FROM 12:00PM-5:00PMIN THEIR CORRESPONDING TIME ZONE.THE ARCHIVED EVENT WILL REMAIN OPEN FOR 30 DAYS.Register today!Visit: www.advanceweb.com/events • Call: 800-546-4987 • Email: ADVANCEevents@advanceweb.comComplete details, session agendas, exhibitor lists, and prizes can be found at www.advanceweb.com/events.ADVANCE for NPs & PAs33

CalendarAESTHETIC EXTENDER SYMPOSIUM20 Category I AAPA CMEJoin us for the exciting and educational Aesthetic ExtenderSymposium November 2 - 4, 2012. Didactic morning sessions arefollowed by afternoon live workshops with an open Q & A forum.This 3 day course will present the full gamut of aesthetic topicsincluding treatments with:Botulinum ToxinCalcium HydroxylapatiteIntense Pulsed LightPhotodynamic TherapyPhotoRejuvenationPhotographyAnestheticsLegal IssuesHyaluronic AcidPoly-L-Lactic AcidFractional ResurfacingCosmeceuticalsNon-Invasive Body ContouringNerve Blocks and TopicalTreatment of Ethnic SkinTattoo RemovalOnly $500 for 3 days of exceptionalaesthetic education in Boca Raton, Florida!Register at:www.aestheticextendersymposium.comRN First Assisting School for the NP or CNSby Professional Assistants PRN since 1986Provides the education the Advanced NursePractitioner needs to assume the role of rstassist and to comply with scope of practicein the role in which they are practicing oranticipate entering.2012 Class Dates:June 21-24September 27-30For additional information/application:RNFA@swfc.edu/rnfa or writeProfessional Assistants PRNC/O SWFC 3910 Riga Blvd.Tampa, FL 33619Meets AORN Education Standardsfor RN First Assistant program andaccepted by CCI.Intensive didactic program withsuture labs followed by anindependent clinical internshipin your facilityIn conjunction withSouthwest Florida CollegeCall 813.630.4401www.professionalassistantsprn.com2012 SPRING SCHEDULEpresentsHands-on Training Seminars and WorkshopsBOTOX/FILLEROrlando, FL ..................................5/5/2012Philadelphia, PA ........................ 5/12/2012Little Rock, AR ........................... 5/19/2012Nashville, TN ............................. 5/19/2012Las Vegas, NV ...............................6/2/2012Minneapolis, MN ..........................6/9/2012Buffalo, NY ................................ 6/16/2012San Francisco, CA ...................... 6/23/2012St. Louis, MO ............................. 6/30/2012Houston, TX ..................................7/7/2012SCLEROTHERAPYHouston, TX ......................................7/8/12MICRODERMABRASION/CHEMICAL PEELSMinneapolis, MN ....................... 6/10/2012Denver, CO................................ 8/19/2012ADVANCED BOTOX/FILLERSOrlando, FL ..................................5/6/2012Philadelphia, PA ........................ 5/13/2012Little Rock, AR ........................... 5/20/2012Nashville, TN ............................. 5/20/2012Las Vegas, NV ...............................6/3/2012• Extensive Hands-On Training• Local Seminars • Small Class SizesVisit our website foradditional seminars and dates.For more information call 512-301-2125Or visit our website atwww.aestheticmedicaltraining.com34 ADVANCE for NPs & PAs

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CalendarLive & Online CE Conferences . . .Over 250,000 healthcare professionals have attended our nationalConferences and readily attest to the quality, attention to detail andprofessional enrichment provided.CE ConferencesPresenting a wide variety of accredited National Conferences, including: Neuro ehabilitation Case Management Critical Care Family Practice Neonatal Obstetrics Pediatrics Pharmacology Primary Care Psychiatric Nursing ducation omens ealthnline CE iraryccess over 1,00 hours of Conference Presentations Onlineincluding C Credit2012 ConferencesPediatric Nursing: Care of the ospitalied Child oston, M May -Psychiatric Nursing Las Vegas, NV May 16-19dvances in ealth Care for omen Over 0 Las Vegas, NV May 17-19dolescent ealth Care an Francisco, C May 31-une Neonatal Pharmacology ashington, C une 7-9Perinatal ilemmas acson ole, uly 1-18NTNP 01: th nternational Nurse ducation Conference altimore, M une 17-0ot Topics in Primary Care acson ole, uly 9-ugust 1Ofce ynecology nowmass, CO ugust -8CN Nurse Manager Priorities Las Vegas, NV eptember 6-8Pharmacology for dvanced Practice Clinicians an Francisco, C eptember 10-16Pediatric Critical Care Nursing Orlando, FL eptember 1-1mbulatory ON Nursing oston, M eptember 7-9North merican Congress of Clinical Toicology (NCCT) Las Vegas, NV October 1-6rain nuries Las Vegas, NV October 3-6Pharmacology for dvanced Practice Clinicians ashington, C October 8-1CN Progressive Care Pathways Las Vegas, NV October 1-17Case Management long the Continuum oston, M October 1-17The Fetus Newborn: tate-of-the-rt Care an Francisco, C October 8-31Contraceptive Technology: uest for cellence tlanta, November 1-3Pharmacology for dvanced Practice Clinicians Las Vegas, NV November -11evelopmental nterventions n Neonatal Care Orlando, FL November 7-10To view a complete list of our conferences visit our website at www.ContemporaryForums.comPhone: (800) 377-7707, Email: info@cforums.comContemoraryormscom onlineCElirarycomMae Contemporary Forums your rst choice for continuing education - Register Today!!SAVE YOURMONEYadvanceprint & digitalsubscriptionsare both FREESUbScRibE TODAY!iT’S EASY!call 800-355-1088 or visitwww.advanceweb.com36 ADVANCE for NPs & PAs

CalendarA P E A’s Adult & Family NP Review Courses2011-2012 SitesBethesda, MD May 3-5Nashville, TN May 14-16Jackson, MS May 18-20San Antonio, TX May 24-26Syracuse, NY May 31-Jun 2Columbus, OH Jun 13-15Houston, TX Jun 29-Jul 1Pomona, CA Jul 11-13Rohnert Park, CA Jul 26-28Lubbock, TX Aug 10-12Memphis, TN Aug 17-19Phoenix, AZ Oct 18-20Visit our website for additional course sites99% Passing RateWe’ll come to your university!Call us for more informationCan’t come to us?APEA’s On-line Review CourseWeb video and multimedia presentations!We guarantee you’ll pass oryour next course is FREE!No bones about it... a 99% pass rate!Weʼve consistently demonstrated a first-attempt pass rateof 99% on both national certification exams for 11 years!Earn 18.5 Contact hours (includes 9.0 pharm hours)Entertaining. Engaging. Energetic speaker!More than exam prep. It's PRACTICE prep.VISIT OUR ON-LINE TESTING CENTER @ www.apea.comSharpen your skills and test your readiness for the certification exam.Identify your strengths and weaknesses with our diagnostic tool!NEW! CE CENTERVIEW streaming video and multimedia presentations! Earn contact hourson your scheduleAdvanced Practice Education Associates800-899-4502 (tel) 337-981-0509 (fax) 103 Darwin Cir. . Lafayette, LA 70508Visit our website: www.apea.com Or e-mail us: courses@apea.comADVANCE for NPs & PAs37

CalendarStethoscope Skills!Improve your physical assessment skills!One day class covers Heart, Breath, & Abdominal Sounds.Everything you need to know about the sounds you hear!Choose from these locations:TexasMay 1 .......................................... San AngeloMay 2 ................................................ OdessaMay 9 .............................................. AmarilloMay 10 ............................................ LubbockMay 11 ..............................................AbileneMay 23 ................................................DallasMay 24 ....................................... San MarcosEast CoastMay 29 ..........................................Edison, NJMay 30 ....................................New York CityJune 5 ........................................Hartford, CTJune 7 ......................................Randolph, MAJune 8 ...................................W. 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Approved 6 CEUs fornurses & respiratoy therapistsFee $79 • Group & Student Discounts AvailableCall 800-227-3372www.stethoscopeskills.comKeep up & staY currentwith ADVANCE online.it’s convenient & good forthe environment!You can manage all theparts of your career withwww.advanceweb.comTHE COLLEGE OF MEDICINE, USAT MONTSERRATwww.usat-montserrat.org • http://usatpga.webs.comBecome a part of the Fastest GrowingHealth Care Professionals (HCP) to MD program in America.The University of Science, Arts and Technology, Montserrat, BWI is inviting applicantsfor the PA to MD and NP to MD transition program. Consists of a 12-month medicalbasic science transition program designed to prepare for USMLE Steps I & II, followed bysupervised clinical training in the USA or abroad. 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Career OpportunitiesLooking for a newcareer opportunity?Each month, the ADVANCE for NPs & PAs OpportunitiesSection presents the latest job openings from acrossthe country. For convenience, listings are arranged byregion, with state headings to further guide yoursearch. These positions are also posted and updateddaily at the “Jobs” tab at our website, www.advanceweb.com/NPPA.Sign up or renew your FREE subscription at thewebsite or by calling (800) 355-1088.To place an ad in this section, call ADVANCE at(800) 355-JOBS (5627).Regional Directory:New England . . . . . . . . . . . . . . . . . . . . . . . . 44Middle Atlantic. . . . . . . . . . . . . . . . . . . . . . . 46Upper South Atlantic. . . . . . . . . . . . . . . . . . 50Lower South Atlantic . . . . . . . . . . . . . . . . . . 52East North Central . . . . . . . . . . . . . . . . . . . 53West South Central . . . . . . . . . . . . . . . . . . . 54Southwest . . . . . . . . . . . . . . . . . . . . . . . . . . 54Mountain . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Pacific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55National . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55NEW ENGLANDNURSE PRACTITIONER OPPORTUNITYJOIN THE HEALTHCARE TEAM ATBERKSHIRE MEDICAL CENTER!Berkshire Medical Center, a 302-bed communityteaching hospital and level II Trauma Center, is currentlyseeking exceptional MA licensed, or licenseeligible, Nurse Practitioners in the following areas:CARDIOLOGYSURGICAL SERVICESOCCUPATIONAL MEDICINEURGENT CAREBerkshire Medical Center is the region’s leading providerof comprehensive health care services. Withaward-winning programs, nationally-recognizedphysicians, world-class technologyand a sincere commitment to the community,we are delivering the kind of advancehealth care most commonly found in largemetropolitan centers.Berkshire Health System offers a competitive salaryand benefits package, as well as the opportunity towork in an environment where you will be challenged,supported, and respected. Relocation assistanceoffered as well. For more information about how youcan become a part of our team, please contact:Antoinette LentineBerkshire Medical Center725 North St., Pittsfi eld, MA 01201Phone: (413) 395-7866Fax: (413) 496-6817E-mail: alentine@bhs1.orgPlease visit our website atwww.berkshirehealthsystems.comEOEMassachusetts, VermontWe Open Doors to BringOut Human PotentialRutland/Killington, VermontWe have good opportunities for mid-level providers inmultiple areas. Competitive salaries with good benefits.Affiliated with Rutland Regional Medical Center.GastroenterologyPhysiatrySend Your Resume to: bbanco@rrmc.orgRebecca Banco, In-house Physician RecruiterRutland Regional Medical Center, Rutland, Vermont • www.RRMC.org• From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't fi nd anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetCall: 1-877-776-6680Visit: advancecustompromotions.com44 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA44 ADVANCE for NPs & PAs

Connecticut, MassachusettsBorn to HealEach of us was born to do something great. Bridgeport Hospital can provide you with a workenvironment that is at once passionate, professional and truly rewarding. A place for you to thrive.Bridgeport Hospital, a member of the world-class Yale New Haven Health System, combines thestate-of-the-art services and technologies of a large, high acuity urban hospital with the personalizedcare of a community hospital.Physician Assistant Opportunities: Yale New Haven Health System, are seeking Physician Assistants to join our multidisciplinary,inpatient, team-based practice. Duties include, but are not limited to, conducting admission historiesand exams, daily rounding on service patients and providing consultation services to the emergencyBridgeport Hospital and NortheastMedical Group offer competitive salaries,commensurate with experience, andgenerous vacation and CME allowance. EOE. Career OpportunitiesORDERREPRINTSTODAYCALL 800.355.5627www.advanceweb.comYOUR ONE-STOP CAREER CENTERPractice the way you were taught!NURSE PRACTITIONER - Full-time positions available inSoutheastern CT to provide health services to clients of Child& Family Agency’s school-based health centers. Benefitpackage includes fifteen vacation days, twelve sick days, elevenpaid holidays, five family days, and medical & dental insurance.Resume, references and salary requirements should be sent to:Personnel Department255 Hempstead StreetNew London, CT 06320Affirmative Action/EOEPlease visit our website www.cfapress.orgSites are NHSC loan replacement sites.Leadership TipsWant to expand your leadership skills?Be agile, embrace unity, provideaccountability, build community, beapproachable, expand responsibility,and think versatility.—Matthew Keane, MPAS, PA-C,in the June 2011 issue ofADVANCE for NPs & PAs.Come work with us!Nurse PractitionerMIT Medical seeks a nurse practitioner tocollaborate with physicians on the provisionof primary and urgent care to patients. Willassess patients’ health status throughinterview and physical exam and synthesizethis clinical information to formulate healthproblem(s) and appropriate treatmentstrategies, and provide health maintenanceand health promotion for patients and theirfamilies. Will provide these services accordingto age-specific plans of care.Requirements: current certification/licensureas a nurse practitioner, current CPRcertification, and two years of experience as anurse practitioner in a relevant age-specificambulatory setting. Experience in dermatologya plus. Hospital-based RN experiencepreferred.MIT Medical is a large multidisciplinary grouppractice serving students, employees,retirees, and families of the MIT community.We have over 25 medical specialties, our ownHMO, a JCAHO-accredited outpatient facility,and close alliances with some of the verybest hospitals in the Boston area. For moreinformation about MIT Medical, please visitour website at http://medweb.mit.edu.Interested candidates may apply on-line athttp://jobs.mit.edu. Please reference jobnumber mit-00008337 and indicate whereyou saw this posting.MIT is an equal opportunity/affirmative actionemployer. Applications from women, minorities,veterans, older workers,and individuals withdisabilities are stronglyencouraged.http://medweb.mit.eduwww.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 45ADVANCE for NPs & PAs45

Rhode Island, New York, New JerseyCareer Opportunities“Connecting Communities to Quality Care”Family and PediatricNurse PractitionerOpportunitiesThe Providence Community HealthCenters Inc., largest network ofcommunity health centers in RhodeIsland, seeks experienced Family andPediatric Nurse Practitioners.Our services include Family andInternal Medicine, OB/GYN, Pediatrics,Allergy/Asthma, Dermatology,Reproductive Health and WIC.Qualifications include: Licensed RNwith Bachelor of Science, CertifiedFamily or Pediatric Nurse Practitionerand 3-5 years of related experience.As a National Health Service CoreApproved Site, school loan repaymentmay be possible. Excellent Benefits.Please forward your resume to:Diana ChristianStaffing SupervisorE-mail: dchristian@providencechc.orgor fax: 401-444-0469MIDDLE ATLANTICNeurosurgicalPhysician AssistantPhysician Affiliate Group of New York(PAGNY) is comprised of over 2000physicians and healthcare professionals whoprovide services to NYC Health and HospitalCorporation (HHC), the largest publichealth system in the United States.We currently have an exciting opportunityavailable at Lincoln Medical & MentalHealth Center in the Bronx, a Level ITrauma and Stroke Center, and acute careteaching hospital affiliated with Weill-CornellMedical College.Requirements include:• Graduation from an accredited PA program• Current NYS PA License & NCCPA Cert• Weekend and day/evening/night shift rotationsExperienced Professionals &New Grads Welcome!To explore other PA openings available atvarious locations throughout NYC, visitthe Careers Section of our website.We offer a competitive salary and benefitspackage. Please apply online at:www.pagny.org/careers.asp.PHYSICIANAFFILIATEGROUP OFNEW YORK, PCAt St. Luke’s Cornwall Hospital, expert medicalcare delivered in a warm, welcoming and compassionateenvironment is the hallmark of service.Our ongoing investment in the people who providecare, the programs and services available inthe community reinforces our continued commitmentto being the health care provider of choicein the mid-Hudson Valley.Our centers of excellence in cancer, cardiac andorthopedic care offer optimum treatment close tohome, while our affiliation with The Mount SinaiHospital extends the scope of resources and experienceavailable to our community.We are currently seeking a full-time NursePractitioner to join our Palliative Care staff. Thecandidate should have a minimum of three (3)years experience as a Nurse Practitioner in a hospitalsetting or physician’s office. Demonstratedknowledge of interdisciplinary team approach.Current knowledge of appropriate technology andpractice standards within palliative care. Strongcommunication skills. Current New York Statelicensure as a Nurse Practitioner. BLS and ACLSrequired. Palliative Care Certification preferred.If you have the passion and experiencenecessary to become part of theSLCH family, you can apply online at:www.stlukescornwallhospital.orgor fax your resume to (845) 568-2164or E-mail: abattle@slchospital.orgGIVE YOURMARKETING ANEW TWIST WITHVisiting Physician Servicesis looking forNURSE PRACTITIONERSEMAIL REPRINTS@ADVANCEWEB.COMto care for elderly homeboundpatients in Monmouth, Ocean andMiddlesex Counties, NJ. Full andpart-time positions are available.PA TimelineIn 1964, Eugene A. Stead Jr., MD,began developing a PA program atDuke University building on the skillsof ex-military corpsmen. He sought toaddress the healthcare provider shortage.In 2011, the number of accreditedentry-level PA programs was 156.• From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't find anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetadvancecustompromotions.comCall: 1-877-776-6680Please fax CV to732-571-1156Physician Assistant position available inpractice of four neurosurgeons in Monmouth County,New Jersey (Shore Area). Expanding practice affi liatedw/major NYC medical center. Excellent benefi ts,including pension.Please e-mail CV to:neurosurgassosbt@yahoo.comand our offi ce will contact you.46 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA46 ADVANCE for NPs & PAs

New Jersey, New YorkLIFESAVINGNEUROSURGERY.*closer to home.When moments matter, we’re ready. How about you?Kennedy Neuroscience Center of Southern New Jersey offers state-of-the-art treatment of brain and spine disorders including braintumors, cerebral hemorrhages, hydrocephalus, spinal cord tumors, compressions, spinal stenosis, and stroke management.Career OpportunitiesBecome part of the future of medicine in South Jersey by joining our top-notch team. Working in this specialized neurosurgical treatmentcenter --- participating in procedures that use technologies found nowhere else in the area --- you’ll be an integral part of lifesaving work. Nurse Practitioner - Full Time Physician Assistant - Full Time*These positions are hospital-based to cover the Neuroscience Program.This comprehensive neurosurgical program is powered by renowned physicians from Jefferson Neurosurgical Associates who performendovascular procedures in Kennedy’s new Hybrid Interventional Neuro Radiology Suite in the OR featuring biplane imaging,a dedicated neurosurgical intensive care unit, advanced imaging and minimally invasive neurosurgery. Kennedy Health System isdesignated as a Primary Stroke Center by the New Jersey Department of Health and Senior Services.A culture of professional growth where our associates are rewarded.EOETo learn more about these exciting opportunitiesand to apply, visit:www.kennedyhealth.orgAs one of the largestmulti-specialtymedical practices onStaten Island, weoffer advanced stateof-the-artmedicaltreatments, expertise and cutting-edge technology.NURSEPRACTITIONERFor Anti-Coagulation ManagementOur newly renovated state-of-the-art facilitiesare a great place to work and we offer attractivesalaries and benefits. Please send resumeincluding a cover letter and salary requirements tohresumes@si-pp.com or Fax: (718) 816-3817.www.si-pp.comEOE M/FProblems inHealthcareThe World Health Organization deemedantimicrobial resistance one of thethree most important problems facinghealthcare providers in 2011.—Lynn A. Kelso, MSN, APRN,FCCM, FAANP, in the February 2012issue of ADVANCE for NPs & PAs.NORTH COUNTRY EMERGENCY MEDICINE CONSULTANTS,PC, is recruiting a Physician Assistant to join our current group of9 Physicians, 5 Physician Assistants, and 2 Nurse Practitioners. NCEMC, PC contracts with Samaritan Medical Center to staff the EmergencyDepartment which has an annual volume of 50,000 patients.PAs, working closely with MDs, staff the ED in both the Urgent Careand Triage areas. SMC recently opened a new ED 11/10 which hasin-ED radiology, CT scan, ED Ultrasound and point of care testing. Thecompensation package is approximately $120,000 PLUS benefits forapproximately 140 hours/month. A RVU-based productivity bonus isrewarded quarterly. Upstate New York is an outdoor enthusiast’s paradisewith 4-season recreation in the world famous Thousand Islands,Lake Ontario and Adirondack regions. Montreal, Toronto, and NYCare a short drive away and Syracuse International Airport is within 1hour drive. If this opportunity interests you, and you have a minimum 3years Emergency Medicine/Urgent Care experience, please send yourCV and cover letter to:Dr. Maja Lundborg-Gray, MD, FAAEM, FACEPPresident, North Country Emergency Medicine Consultants, PCSamaritan Medical CenterDepartment of Emergency Medicine830 Washington StreetWatertown, NY 13601Or e-mail to:MLGRAY@SHSNY.COMwww.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 47ADVANCE for NPs & PAs47

Career OpportunitiesPennsylvania, New Jerseyyears agoyou madea promise(so did we)...your future’s callingYou set out to help people. To find a setting that encouraged you to learn, grow,and connect. You wanted to do all you were capable of – and more.That place really does exist. We promise.HOLY REDEEMER LAFAYETTE8580 Verree Rd., Philadelphia, PANurse Practitioner (Long Term Care/Short Stay Rehab)As a Long Term Care Nurse Practitioner, you will provide a high level of holistic care and servicesfor the resident while serving as a clinical expert for the Interdisciplinary team and the family. You willact as a liaison to physicians to ensure all resident and family needs are being met. The successfulcandidate will be a graduate from an accredited Nurse Practitioner Program with a Master’s Degreein Nursing, and certified as a Nurse Practitioner by American Nurses Association. Formal educationin the area of Gerontology; minimum of 2 years experience working with adult or geriatric population.To discover more about this rewardingposition, to apply online, and to read aboutour mission, community and our people, visitus online at:www.holyredeemer.comor call Alisa Cohen at 215-214-0681EOE1 step must start each journey.At Kennedy Health System, ourNurse Practitioners serve as patientadvocates, using their skills andexperience to provide optimal care toour patients and their families. Our NPsexcel in situations requiring complexassessments, high-intensity therapiesand interventions, and continuousnursing vigilance. We are seeking NursePractitioners for our Stratford, NJCampus: Geriatrics: Full Time Occupational Health: ReliefKennedy supports Nurse Practitionerswith a competitive compensationpackage.Apply online:www.kennedyhealth.orgEOEOpening for a Full-Time Nurse PractitionerMercy Philadelphia Hospital’s WorkCare and Employee Health Department is seeking afull-time Nurse Practitioner. The person is scheduled to work weekdays from 7:30 a.m.to 4:00 pm. The Nurse Practitioner will provide medical services to the area employersand insurers that use Mercy WorkCare for their occupational health needs, in addition toemployee health services to MPH’s employees.This position requires a Current Pennsylvania Nurse Practitioner License, formal trainingin occupational medicine preferred, a current CPR certification, and at least two years ofexperience in Occupational Medicine.Competitive salary and benefits packages.Mercy Philadelphia Hospital, part of Mercy Health System, the largest Catholic healthcaresystem serving the Delaware Valley, provides accessible, high-quality medical servicesand programs delivered with excellence and compassion.Qualified candidates can apply on-line at www.mercyhealth.org. EOE02-04719NURSE PRACTITIONERS(FNP)PA, NJ and DE areasBilingual a PlusWe will Educate andTrain for DermatologyExcellent Salary & Benefits,Vacation, Incentives, &Time off for CMEs.Call 732.814.0769 • Fax 732.608.7410E-mail: jerryvm@go2derm.comCRNP or PAneeded Full-time1+ years experience, for busy Family Practicespecializing in Weight Loss. Phila. & Bucks Co.offi ces. Send resume and letter to:medicalw8loss@aol.comDr. Fisher’sMedical Weight Loss& Aesthetic Centers48 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA48 ADVANCE for NPs & PAs

New Jersey, PennsylvaniaTreating you better…for life.Physician AssistantDepartment of SurgeryExcellent opportunities are now available for enthusiastic,highly motivated Physician Assistantsto join the Department of Surgery as part of amulti-specialty, team oriented Physician AssistantProgram. Responsibilities include obtaininghistory and physicals, surgical consent, pre &post-operative evaluation and management, ERadmissions, surgical consults, daily inpatientrounds, assisting in the operating room, andserving as a liaison between patients, familymembers, the referring physician, the nursingstaff and training programs. NCCPA certificationand NJ license required. Surgical exp req’d.Please send your resume along with salaryhistory and requirements toHuman Resources Dept-KCEmail: kcarroll@saintpetersuh.comFax 732-220-8046or apply online atwww.saintpetershcs.com/CareerCenterImmediate Openings forNurse Practitionersand Physician Assistantsin Berks County, PA!The Reading Hospital and Medical Center has immediateopenings for Nurse Practitioners and Physician Assistantsin the following specialty areas:• Emergency Medicine (NP or PA)• Geriatrics (NP or PA)• Infectious Diseases (NP)• Interventional Radiology (PA)• Neurosurgery (NP or PA)• OBGyn (NP)• Occupational Medicine (NP)The Reading Hospital and Medical Center is a not-forprofithealthcare center providing comprehensive acutecare, post-acute rehabilitation, behavioral, and occupationalhealth services to the people of Berks and adjoining counties.Established as The Reading Dispensary in 1867, theHospital has since expanded into a leader in tertiary carefor this region of Pennsylvania.Career OpportunitiesA MEMBER OF SAINT PETER’S HEALTHCARE SYSTEM254 Easton Avenue, New Brunswick, NJ 08901www.saintpetershcs.comEOEThe Reading Hospital offers a competitive compensationpackage, comprehensive benefi ts, and occurrence-basedmalpractice insurance.To apply, send your resume toMaddie Wagner at madeline.wagner@trhmg.orgor apply online at www.readingdocs.orgLearn About Nursing’sBest Kept Secrets...Let’s Speak. –NancyIf you’d like to hear about great opportunities that youmay not have thought of, speak to Nancy. She can tellyou about the rewards of careers in correctional andoutpatient nursing, answer your questions while youtour a facility, and tell you about the opportunities forprofessional growth and advancement.PSYCHIATRIC APNWellness / Recovery Centert Clres elt ystesCrss nterventon rorFlexible Hours. Experienced Prescribing APN.Current NJ RN / NP and DEA andCDS licenses required.MEDICAL NPsFull-time, M-F, Essex County Jail.Per diem at Hudson, Middlesex,Camden and Atlantic.We offer excellent compensation.Full-Time employees enjoy agenerous benefits package.Call or send resume:Nancy DeLapo,Director of Staff DevelopmentPhone 856-797-4761NDeLapo@cfgpc.comFax 856-797-4798www.cfghealthsystems.comEOEInflammatoryBreast CancerJulie A. Nelson, DNP, RNC-OB, WHNP-BC,Deepa Patel, BSN, CCRN, ANP-S, andPeggy Mancuso, PhD, RN, CNM, listedredness and color change, swelling,induration or ridges, skin thickening,heaviness or fullness in breast, sensationof heat in breast, palpable lymphnodes, sudden increase in breast size,little or no response to antibiotic treatment,and rapid progression of symptomsas key clinical features of inflammatorybreast cancer in the October2011 issue of ADVANCE for NPs & PAs.PEDIATRIC NURSEPRACTITIONERPediatric group with offices inAtlantic City and Egg HarborTownship, NJ seeking certifiedor experiencedPediatric Nurse Practitioner.Excellent salary and benefits.Please e-mail CV toJeanniecostellobp@comcast.netor call 609-348-4813Visit us atwww.brightonpediatrics.netwww.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 49ADVANCE for NPs & PAs49

Career OpportunitiesCollaboration...is working as a team to providequality personalized care.Family NursePractitionersFull timePhysician Practices in Northern NJM-F w/alternate weekends andone early eveningPer DiemOccupational & EmployeeHealth Center - varied daysM-F 8am-4:30pmRequirements:• Current license NJ RN and AdvancedPractice nurse• Cert as FNP by NJBON• Eligibility for prescriptive practice in NJ• Current BLS• Min 5 years RN exp w/3 yrs in area ofspecialityFor full details and application visitwww.chiltonhealth.orgFax: 973.831.551697 West Parkway,Pompton PlainsNJ 07444New Jersey, Maryland, Pennsylvania20-person Multi-Specialty groupin Clifton, NJ, looking for aNurse Practitioner with anemphasis on women’s health.973-594-1707 x4005; njpllc.comNurse Practitioner/Physician AssistantFT/PT for busy Family Practice inBergen County, NJ. New Grads Welcome.E-mail resumé to eimperiosi@optonline.netor Fax: 201-368-9618Surgical InfectionSurgical site infections affect 750,000U.S. patients every year.—Robert M. Blumm, MA, PA-C,DFAAPA, in the February 2012 issueof ADVANCE for NPs & PAs.UPPER SOUTH ATLANTICSMLancaster General Health has a varietyof opportunities available.Positions include:Nurse PractitionerFull-time positions available in Heart Failure, Electrophysiology,Family Medicine, Internal Medicine(night shift, 7 on/ 7 off), Psychiatry, TraumaPhysician AssistantFull-time in TraumaPhysician Assistant/Nurse PractitionerFamily MedicineWe offer an excellent benefits package, includingthe ability to purchase Medical/Dental insurance,paid malpractice insurance and more.For further information and confidential consideration,send resume/CV to Beth A. Calabria atbcalabria2@lghealth.orgFax 717.544.1902Visit our website at www.lancastergeneral.orgEqual Opportunity EmployerCHILTONHOSPITALwww.chiltonhealth.orgNursePractitionerFast-paced Cardiology Practice locatedin South Jersey seeks FT APN witha strong background in Cardiology.Responsibilities include history andphysicals and clinical evaluation andmanagement of hospitalized patients.Also responsible for admission anddischarge of hospital patients, patientand family education, telephone followupsand rounding with physicians.Current NJ Advanced Practice Nursinglicense and ACLS/BLS cert. required.E-mail CV to sthomas@accnj.comor fax to: 856-673-1359. EOE50 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA50 ADVANCE for NPs & PAs

MarylandCareer OpportunitiesThe advanced practice nurse you’re prepared to be is waiting.At a place where advanced nursing is so established in the care model,you can work at the vanguard, without blazing the trail.And where, for more than 240 NPs, CRNAs, CNSs and CNMs,a job has become a mission.Sound interesting? Meet some of your new peers at umm.edu/nursing.Watch their videos. Then, connect with them on Facebookto get even more scoop. You’re going to fit right in.University of MarylandMedical CenterMEDICINE ON A MISSION SMfacebook.com/marylandnursing@UMMCnursing© University of Maryland Medical Centerwww.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 51ADVANCE for NPs & PAs51

Delaware, Maryland, FloridaCareer OpportunitiesJobs to watchat Beebe.Beebe Medical Center - located in beautiful and historic Lewes, Delaware, near Rehoboth Beach - has the following opportunities availablefor experienced Nurse Practitioners and Physician Assistants:• Nurse Practitioner/Physician Asst. - Wound CarePhysician Assistant or Nurse Practitioner Program. Current Delaware Licensure required. Experience as a Nurse Practitioner in anoutpatient setting preferred.• Nurse Practitioner - Interventional Cardiology - Current Delaware Advanced Practice Nurse licensure• Nurse Practitioner/Physician Asst. - Pulmonary/Critical Care - Current Delaware PA or NP• Nurse Practitioner - Observation UnitMust have valid Advanced Practice licensure in Delaware.Please visit our website to apply online, and for more information/detailed job descriptionswww.beebemed.orgPhone: 302-645-3336Fax:Email:www.facebook.com/beebecareersMaryland Correctional MedicineWe are searching for Nurse Practitioners andPhysician Assistants to join our team inMaryland. We have correctional facilities inWestover, Cumberland, Hagerstown, Baltimoreand Jessup. Excellent benefits and salary.Please submit your resume to:Timothy R. Kehler for consideration.Tim.kehler@corizonhealth.comPhysician AssistantPart-Time Physician Assistant needed for FamilyPractice/Occupational Medicine. No Call, Noweekends. Must have 1 Year experience and acurrent Maryland License. Competitive pay.Available immediately.To apply, send resume to: olmspc@yahoo.comor visit us at www.convenienthealthcare.bizNurse Practitioner/Physician AssistantBaltimore $125k+Exceptional opportunity for sharp & experienced NP or PA-C. Must haveexcellent clinical/people skills, strong work ethic, stable work history &excellent references. Prestigious specialty practice offers very competitivesalary + bonus structure! If you are at the top of your game, sendyour resume to: harrisonsandra1976@gmail.com. Please includea day/evening telephone number where you may be reached.Influenza TreatmentInfluenza affects an average of 5% to20% of the U.S. population and resultsin more than 200,000 hospitalizationsannually. The best treatment is vaccinationagainst the disease and its mostcommon complication, pneumonia.—Debra Schuerman, NP,in the November 2011 issue ofADVANCE for NPs & PAs.LOWER SOUTH ATLANTICWWW.HPPARTNERS.COMEmergency Medicine JobsHospitalist Medicine Jobs888.654.145852 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA52 ADVANCE for NPs & PAs

South Carolina, Florida, North Carolina, IllinoisCareer OpportunitiesEmergency Medicine NP/PACape Coral/Fort Myers, FloridaExperienced Emergency Medicine NP orPA wanted for Full or Part-time positions.Beautiful Florida Gulf Coast communitywithin close proximity to beaches, fi shingand boating. Great autonomy and physicianback up in a team environment. Competitivehourly pay with generous evening and nightdifferential. Excellent compensation packagefor full-time employment. Solid emergencymedicine experience required for thisposition. Please no new graduates.Contact Heather WrayHLZRN@yahoo.comadvancecustompromotions.com1-877-776-6680PhysicianAssistantFull-time Positions - Raleigh Location. Raleigh Orthopaedicseeks North Carolina licensed Physician Assistants to join ourestablished team of mid-level practitioners and Orthopaedic surgeonsin providing quality patient care. We have opportunities working withfellowship trained Orthopaedic surgeons in the specialties of SportsMedicine and Hand & Upper Extremity.Must be able to work independently and be comfortable interpretingX-rays. Requires appropriate certifi cation and NC licensure. Prefer 1to 3 years experience but will consider new grads. Athletic Trainingbackground preferred for Sports Medicine opportunity.Resumes should be forwardedwith cover letter to hr@raleighortho.comJob SatisfactionNPs consider continuing education support,monetary bonuses in addition tosalary, and opportunity to receive compensationfor services outside normalduties on the job less important thanintrinsic factors. They are most satisfiedby percentage of time spent in directpatient care, sense of accomplishment,and ability to deliver quality care.—Ann Priebe, MSN, ACNP-BC,in the February 2012 issue ofADVANCE for NPs & PAs.EAST NORTH CENTRALNurse Practitioner OpportunitiesOutpatient Full-Time/ Part-TimeNew retail quick care clinic in theLakeview area of Chicago withopportunity for continuity care androtation to immediate care clinics.CNP with strong customer service skills.Experience/training in family medicine,urgent care, ER or retail health.FT & PT openings.Competitive benefit/salary package.Send inquiries to:jigar.patel@reshealthcare.orgPhone: 773-990-8924RENEW YOUR FREESUBSCRIPTION NOW!CALL 800.355.1088www.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 53ADVANCE for NPs & PAs53

Texas, New MexicoCareer OpportunitiesWEST SOUTH CENTRALMBS Integrated Care, a division of Harden Healthcare,provides Mid-Level providers in the long-term care andhome health setting. We are a growing company withopportunities available across Texas. We are currentlyseeking Mid-Level providers for the followinglocations:Nursing Home Providersand Home Care Providers:• EL PASO • FREDERICKSBURG• BEAUMONT/PORT ARTHUR/ORANGE• DENISON • SAN ANTONIO• CORPUS CHRISTI • CORSICANA • TEMPLEIf you are interested in a great opportunity withan expanding organization please contact:Tracy Shultz, Recruiter attshultz@hardenhealthcare.comor by phone at 1-866-607-2722.Feel free to visit our website to learn more:www.hardenhealthcare.comwww.mbsintegratedcare.comAssistant, Associate or Full Professor:Req 2012000387 School of Nursing,New Mexico State University:Applications are invited for a 9-month, tenure track faculty position, with supplemental summeremployment possible. Minimum Qualifications: Master’s degree in nursing is required.Clinical experience and current national certification as a nurse practitioner is required. Mustbe eligible for NM nursing license. Preferred Qualifications: completion of a DNP and/ orPhD in nursing or closely related discipline. Previous teaching experience at baccalaureate orhigher degree level is preferred. A detailed position announcement is available at http://hr.nmsu.edu/employment/. Applicants: Submit: (1) a cover letter describing your interestsand qualifications for the position and addressing both the minimum and preferred qualificationsfor the position; (2) A curriculum vita; (3) the names, addresses,telephone numbers, email contact information for three references to:Dr. Pamela Schultz, Assoc. Dean & Director of SON, NMSU- School of Nursing, MSC 3185, PO Box 30001, Las Cruces,NM 88003-8001. Tel: 575-646-3812, Fax: 575-646-2167,Email: pschultz@nmsu.edu. Review of applications will begin June1, 2012 and applications received after this date may be considered.Senior PsychCareprovides evaluations, psychiatric management and mentalhealth services to nursing home residents throughout thestate of Texas. NP or PA with Geriatric or Psychiatricexperience preferred but willing to train. TX license,PT/FT/PRN available, EMR, fl exible schedules, full benefi ts.San Antonio, Houston, Austin, Dallas.advancecustompromotions.com1-877-776-6680lmatthews@seniorpsychiatry.com or fax 713-627-7302• From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't find anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetSOUTHWESTDiscover an unparalleled academicmedical center experience whereyou least expect it.Think achievement.Think UNM Hospitals.At the University of New Mexico Hospitals,our real difference is the one that only youcan make. Our numerous accreditations,recognition, and honors are a result of ourcontinued commitment to the expertise andcontinued growth of our team members. Whenyou join UNMH, you become the reflection ofour quality of care, leadership as the only LevelI Trauma Center in the state, and the conduitfor each patient’s successful outcome.Nurse Practitioners/Physician AssistantsPsych • Primary Care • Specialty • InpatientBring your expertise to UNMH, and redefineyour career with an organization committedto supporting your career quality and growth.We are recognized as a quality leader and forour leadership across stroke, trauma, and 13pediatric subspecialties.Learn more about UNMH and apply to ourlatest openings at http://hospitals.unm.edu/jobsEOEFriend us at:facebook.com/UNMHospitals.54 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA54 ADVANCE for NPs & PAs

Idaho, Alaska, Oregon, NationalMOUNTAINNP/PA for Urgent Care in SW IdahoWe are seeking a Full Time NP/PA withUrgent Care experience to join us.The providers at Saint AlphonsusMedical Group are part of a medical teamof over 200 board-certified physicians andmid-levels at 38 clinics throughout SWIdaho.Excellent salary and benefits.Sylvia Chariton 800-309-5388,e-mail sylvchar@sarmc.orgor fax CV to 208-367-7964NURSE PRACTITIONER/PHYSICIAN ASSISTANT OPPORTUNITIESPeaceHealthSacred Heart Medical CenterPeaceHealth Medical GroupLocated in the lush Willamette Valley between the rugged PacicCoast and the magnicent Cascade Mountains, Eugene, Oregonis a welcoming blend of cutting-edge culture and breathtakingwilderness. Guided by our mission and values, PeaceHealthprovides evidence-based and compassionate healthcare in thePacic Northwest.PeaceHealth Medical Group is seeking experienced, board certi-ed Nurse Practitioners/Physician Assistants to join our group.We have opportunities in:ANP • FNPNeurohospitalist NP • Hospitalist NPUrgent Care NP • PMHNPCardiovascular NP/PAWound and Ostomy NPGNP • Cardiology Outpatient NPIf you are looking for a career that engages your heartas well as your mind, we encourage you to consider PeaceHealth.Please visit our website at www.peacehealth.org.Contact Brooke Hausmann at 541-222-2508 or e-mail atbrhausmann@peacehealth.org for more information or to apply.Career Opportunitieshttp://www.saintalphonsus.org/career-video.htmlPACIFICBeautiful Southern Oregon - Grants PassSeeking two experienced certified FNPs for in-house positions inacute care and primary care. Guaranteed salary and generous benefits.No call requirements. Financially healthy multi-specialty groupserving southern Oregon for over 58 years. Annual Salary 94k.Visit our website at www.grantspassclinic.com. Contact SusanSartain by e-mail at ssartain@grantspassclinic.com or bytelephone at 541-472-5505.NATIONALMedical VisitsAs many as 80% of visits to U.S.healthcare providers are from patientswho have medically unexplained symptomsand/or pain.Orthopaedic PASeeking an experienced Ortho PA.Includes clinic, surgical & some trauma.Call required.888-890-8301, ext. 1907-228-8324 (fax)kghrecruiters@peacehealth.orgwww.peacehealth.orgPA DemandThe American Academy of PhysicianAssistants reported in September 2011that the number of practicing PAsreached 83,466 in 2010 – a 100%increase since 2000.—Michelle Perron Pronsati, editor,in the October 2011 issueof ADVANCE for NPs & PAs.The Sign of Excellence in Emergency Medicine ®Current Opportunities:New Jersey:•Bayshore Medical Center, Holmdel, NJ•Clara Maass Medical Center, Belleville, NJ•Kimball Medical Center, Lakewood, NJ•RWJ Rahway Hospital, Rahway, NJ•Newton Medical Center, Newton, NJEmergency Medical Associateshas full-time and per diem positions forPhysician Assistants andNurse Practitioners on the East Coast.Rhode Island:•Our Lady of Fatima Hospital, North Providence, RI•Roger Williams Medical Center, Providence, RINew York:•The Kingston Hospital, Kingston, NY•St. Peter’s Hospital, Albany, NYNorth Carolina:•Southeastern Regional Medical Center, Lumberton, NCEnjoy excellent compensation, comprehensive benefi ts (Full Health, 401k match, Profi t Sharing, PTO and ProfessionalExpenses) and career growth with a nationally recognized democratic group that is committed tolife-work balance.Contact: Dan Rizzo877-692-4665 x1048RizzoD@alpha-apr.comwww.ema.net/careersDON’T LET YOUR FREESUBSCRIPTION TO ADVANCE EXPIRE!CALL 800.355.1088www.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 55ADVANCE for NPs & PAs55

NationalCareer OpportunitiesUP-TO-THEMINUTE NEWSCONVENIENTLYDELIVERED TOYOUR EMAILACCOUNTSIGN UP NOWFOR YOUR FREEE-NEWSLETTERTHE STRENGTH TO HEAL and thetechnology to give our Soldiers the best care.As a physician assistant in the U.S. Army Reserve, you’ll have access to state-of-the-arttechnology and the most advanced facilities. You’ll be able to continue to practice in yourcommunity and serve when needed. And regardless of where you serve, you’ll be anofficer and proud member of one of the world’s largest and most advanced healthcare systems.To learn more about the U.S. Army Reserve health care team, call855-276-9770 or visit healthcare.goarmy.com/info/q455.©2012. Paid for by the United States Army. All rights reserved.56 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA56 ADVANCE for NPs & PAs

NationalCHECKOUTAND LINK TOYOUR FAVORITEADVANCEMAGAZINE,JOB SEARCH,SHOPPING ,CE AND MORE!Micromanagementitis 251Micromanagementitis|mı-kro-man-ij-men-tı-tes|DEFINITIONa condition affecting healthcare professionals who feel like they’renot in complete control of their next moveTREATMENTbecome a Nurse Practitioner on the Take Care HealthSystems SM team and use your skills and clinical judgmentto deliver care autonomouslyAt Take Care Health Systems, werespect the important role thatNurse Practitioners play.That’s why we’ve created an autonomousworkplace—one that trusts you to assessyour patients’ needs on a case-by-casebasis, and to use your clinical judgment totreat your patients and create preventionand wellness programs based on theirexact needs.As part of Walgreens Health and Wellnessdivision, Take Care Health Systems isthe nation’s largest provider of worksitehealth and wellness services, with over40 years of industry experience.Nurse Practitioner opportunitiesare currently available Nationwide,including:• Winston Salem, NC• Whitakers, NC• Laporte, TX• Ardmore, OK• Lake Tahoe, NV• Hillsboro, ORFor more information and to apply, please visit:TakeCareCareers.com/nursepractitionerTake Care Health Systems SM is proud to be an EqualOpportunity Employer. Take Care Health Systems is a whollyowned subsidiary of Walgreen Co. that manages worksitehealth and wellness services. Physician and certain directpatient care services are provided through an independentprofessional corporation.CareMore is hiring NursePractitioners!As a leader in senior healthcare for over 20 years, our vision is to significantly improve the lives of Medicarerecipients by employing a dedicated staff of professionals who are passionate about changing lives. Whenyou join CareMore, we’ll give you every opportunity to make a real difference. As a Nurse Practitioner,you will be the leading care provider for patients in our CareMore Care Centers or in institutionalizedsettings such as nursing homes, assisted livings, and board & care facilities.Career OpportunitiesBenefits of SunExposureExposure to sunlight helps prevent andtreat seasonal affective disorder, andUVA exposure plus psoralen can helptreat psoriasis. Sunlight is also essentialfor vitamin D production, which isimperative for bone development, bonestrength and prevention of rickets, certaincancers and heart disease.CareMore offers competitive compensation, bonus and growth opportunities, and a comprehensivebenefits package to include: medical, dental, vision, life, long term disability, flexible spendingaccounts, 401(k), PTO, paid holidays.If you are a compassionate Nurse Practitioner who shares our commitment to provide focused and innovativemethods of managing chronic disease, frailty and end of life, pleaseapply today! Be More with CareMore.CareMore is hosting job fairsin Richmond, VA, on June 7, 2012and in Brooklyn, NY, on June 14, 2012!To apply directly and learn moredetails about the job fair,please visit our website at:http://www.caremore.com/About/Careers.aspxTRY ADVANCE REPRINTS! CALL 800-355-5627www.advanceweb.com/NPPA • ADVANCE for NPs & PAs • May 2012 57ADVANCE for NPs & PAs57

NationalCareer Opportunitiesadvancecustompromotions.com1-877-776-6680• From the publishers of ADVANCE Newsmagazines• Custom gifts, giveaways & promotional products• Exclusive healthcare designs you won't find anywhere else• Free design, copy & creative services• Staff gifts & event giveaways for every budgetYOURONE-STOPCAREERCENTERWWW.ADVANCEWEB.COMGERD PrecautionsKristy L. Oden, DNP, FNP-BC, MSN,RN, recommends avoiding carbonatedbeverages, spicy foods, alcohol, chocolate,acidic fruits and fruit drinks toreduce gastroesophageal reflux disease.Reported in the August 2011 issue ofADVANCE for NPs & PAs.WITH JUST ONE NAME TO REMEMBER,SEARCHING FOR INFORMATION ON THEWEB JUST GOT EASIER!58 May 2012 • ADVANCE for NPs & PAs • www.advanceweb.com/NPPA58 ADVANCE for NPs & PAs

CCharting BetterPatient OutcomesELEBRATING20 yearsFlorajen unites high potency with affordability.600billioncellsBeneficial BacteriaLive Cells per BottleCost Per Bottle$43.95450billioncells$22.99$29.99300billioncells$11.95$14.9528billioncellsNocells *Florajen Florajen3 Culturelle Align Florastor Florajen Florajen3 Culturelle Align Florastor* No beneficial bacteria—only Saccharomyces, a probiotic yeastFlorajen is formulated with proven safe and effectivestrains. Its higher cell count delivers a level of potencywith real and significant health benefits. Unlike theleading competitors, Florajen is refrigerated for freshnessand quality and it is affordable for all your patients.For Free Sample Packs to get your patients started,call 1-800-257-5433 or visit florajensamples.com!TheMost Effectiveand AffordableProbioticsAvailable †Refrigeratedfor Freshness& MaximumPotencyHigh Potency Probioticswww.florajen.comAvailable inpharmacists’refrigerators andstore coolersnationwide† Florajen contains more live probiotic and bile tolerant cells per dollar spent than any competitor.Statements have not been evaluated by the Food and Drug Administration.This product is not medicinal and is not intended to diagnose, treat, cure or prevent any disease.©2012 American Lifeline, Inc. All rights reserved. 0412ADVANCE for NPs & PAs59

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